Provider Demographics
NPI:1033309372
Name:MINUTECLINIC DIAGNOSTIC MEDICAL GROUP OF CALIFORNIA, INC.
Entity Type:Organization
Organization Name:MINUTECLINIC DIAGNOSTIC MEDICAL GROUP OF CALIFORNIA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:PINCINCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-770-3813
Mailing Address - Street 1:PO BOX 772
Mailing Address - Street 2:PAYOR ENROLLMENT-MC 2295
Mailing Address - City:WOONSOCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02895-0784
Mailing Address - Country:US
Mailing Address - Phone:866-389-2727
Mailing Address - Fax:401-406-3539
Practice Address - Street 1:511 N HOLLYWOOD WAY
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-3406
Practice Address - Country:US
Practice Address - Phone:866-389-2727
Practice Address - Fax:401-406-3539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-01
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADO3845OtherMEDICARE RAILROAD
CACA129876Medicare PIN
CADO3845OtherMEDICARE RAILROAD
CACA128800Medicare PIN
CACA110976Medicare PIN
CACB206670Medicare PIN
CABE830AMedicare PIN