Provider Demographics
NPI:1003188160
Name:MAYFLOWER MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:MAYFLOWER MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTRACTS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ARACELI
Authorized Official - Middle Name:
Authorized Official - Last Name:FUENTES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-800-1200
Mailing Address - Street 1:140 N ORANGE AVE.
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-2032
Mailing Address - Country:US
Mailing Address - Phone:626-800-1200
Mailing Address - Fax:626-962-2471
Practice Address - Street 1:140 N ORANGE AVE.
Practice Address - Street 2:SUITE 100
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-2032
Practice Address - Country:US
Practice Address - Phone:626-800-1200
Practice Address - Fax:626-962-2471
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-06
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA46009207Q00000X
207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6409040Medicaid
CA6409040Medicaid