Basic Information
Provider Information | |||||||||
NPI: | 1629607676 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SJ MEDICAL GROUP OPERATED BY NEIGHBORHOOD HEALTHCARE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 425 N DATE ST | ||||||||
Address2: |   | ||||||||
City: | ESCONDIDO | ||||||||
State: | CA | ||||||||
PostalCode: | 920253413 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7607376935 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 422 N SAN JACINTO ST STE A | ||||||||
Address2: |   | ||||||||
City: | HEMET | ||||||||
State: | CA | ||||||||
PostalCode: | 925433124 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7605208300 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/02/2020 | ||||||||
LastUpdateDate: | 04/02/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PATEL | ||||||||
AuthorizedOfficialFirstName: | RAKESH | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 7607376925 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: | 04/02/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.