Provider Demographics
NPI:1003846486
Name:HEALTHCARE PROVIDERS OF CALIFORNIA MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:HEALTHCARE PROVIDERS OF CALIFORNIA MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:GIAQUINTO
Authorized Official - Suffix:JR
Authorized Official - Credentials:PHD
Authorized Official - Phone:818-421-2799
Mailing Address - Street 1:24425 WOOLSEY CANYON RD
Mailing Address - Street 2:#11
Mailing Address - City:CANOGA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91304-1131
Mailing Address - Country:US
Mailing Address - Phone:818-713-1115
Mailing Address - Fax:818-713-1116
Practice Address - Street 1:342 W SAN YSIDRO BLVD
Practice Address - Street 2:#F
Practice Address - City:SAN YSIDRO
Practice Address - State:CA
Practice Address - Zip Code:92173-2495
Practice Address - Country:US
Practice Address - Phone:619-662-3880
Practice Address - Fax:619-662-2942
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA51621207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW16187BMedicare ID - Type UnspecifiedGROUP PRACTICE