Basic Information
Provider Information | |||||||||
NPI: | 1679749501 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MORENO VALLEY FAMILY HEALTH CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MORENO VALLEY FAMILY HEALTH CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 22675 ALESSANDRO BLVD | ||||||||
Address2: |   | ||||||||
City: | MORENO VALLEY | ||||||||
State: | CA | ||||||||
PostalCode: | 925538551 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9515712300 | ||||||||
FaxNumber: | 9515712330 | ||||||||
Practice Location | |||||||||
Address1: | 22675 ALESSANDRO BLVD | ||||||||
Address2: |   | ||||||||
City: | MORENO VALLEY | ||||||||
State: | CA | ||||||||
PostalCode: | 925538551 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9515712350 | ||||||||
FaxNumber: | 9515712370 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/30/2008 | ||||||||
LastUpdateDate: | 03/20/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HOLEMAN | ||||||||
AuthorizedOfficialFirstName: | LORI | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 9515712300 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | COMMUNITY HEALTH SYSTEMS, INC. | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | A99343 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | 550000802 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   | 1223G0001X | 46894 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice | 1223P0221X | 47987 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Pediatric Dentistry | 152W00000X | OPT5169TPA | CA | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |   | 207Q00000X | 6440 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | A50693 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | 11428 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   | 207V00000X | 10648 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   | 363LF0000X | 436046 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 122300000X | 40093 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist |   | 122300000X | 27343 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist |   | 261QF0400X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | NPI 1679749501 | 05 | CA |   | MEDICAID |