Basic Information
| Provider Information | |||||||||
| NPI: | 1699071753 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FACULTY MEDICAL GROUP OF LLUSM | ||||||||
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| OtherOrganizationName: | FMG OF LLUSM-ED URGENT CARE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | FILE NO 54701 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900744701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095583111 | ||||||||
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| Practice Location | |||||||||
| Address1: | 28078 BAXTER RD | ||||||||
| Address2: | |||||||||
| City: | MURRIETA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9512906366 | ||||||||
| FaxNumber: | 9512906990 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2011 | ||||||||
| LastUpdateDate: | 02/07/2011 | ||||||||
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| AuthorizedOfficialLastName: | WOLTER | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PROVIDER ENROLLMENT REP | ||||||||
| AuthorizedOfficialTelephone: | 9095583289 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FACULTY MEDICAL GROUP OF LLUSM | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PS0010X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Sports Medicine | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.