Basic Information
| Provider Information | |||||||||
| NPI: | 1760802805 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TEMECULA VALLEY FAMILY MEDICAL GROUP | ||||||||
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| OtherOrganizationName: | TEMECULA VALLEY FAMILY MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 27475 YNEZ ROAD | ||||||||
| Address2: | SUITE 313 | ||||||||
| City: | TEMECULA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9517649673 | ||||||||
| FaxNumber: | 9099416974 | ||||||||
| Practice Location | |||||||||
| Address1: | 9380 7TH STREET | ||||||||
| Address2: | SUITE H | ||||||||
| City: | RANCHO CUCAMONGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9094842865 | ||||||||
| FaxNumber: | 9099416974 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2014 | ||||||||
| LastUpdateDate: | 04/16/2014 | ||||||||
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| AuthorizedOfficialLastName: | QUIJADA | ||||||||
| AuthorizedOfficialFirstName: | EARL | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9517649673 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | A60997 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 00A609970 | 05 | CA | MEDICAID |