Basic Information
| Provider Information | |||||||||
| NPI: | 1659886125 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOLINA HEALTHCARE OF CALIFORNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 OCEANGATE STE 100 | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908024317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8885625442 | ||||||||
| FaxNumber: | 5624996171 | ||||||||
| Practice Location | |||||||||
| Address1: | 14544 7TH ST | ||||||||
| Address2: | |||||||||
| City: | VICTORVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923954214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602451025 | ||||||||
| FaxNumber: | 8774698906 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2017 | ||||||||
| LastUpdateDate: | 12/06/2017 | ||||||||
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| AuthorizedOfficialLastName: | SCHUEREN | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
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| AuthorizedOfficialTitleorPosition: | V.P. FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 8885625442 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.