Provider Demographics
NPI:1043630106
Name:YOUR MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:YOUR MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO-PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RAY
Authorized Official - Middle Name:
Authorized Official - Last Name:KUSUMOTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:831-531-4213
Mailing Address - Street 1:591 MCCRAY ST
Mailing Address - Street 2:SUITE 211
Mailing Address - City:HOLLISTER
Mailing Address - State:CA
Mailing Address - Zip Code:95023-2224
Mailing Address - Country:US
Mailing Address - Phone:831-531-4213
Mailing Address - Fax:
Practice Address - Street 1:591 MCCRAY ST
Practice Address - Street 2:SUITE 211
Practice Address - City:HOLLISTER
Practice Address - State:CA
Practice Address - Zip Code:95023-2224
Practice Address - Country:US
Practice Address - Phone:831-531-4213
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-16
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty