Provider Demographics
NPI:1073669404
Name:CANYON SPRINGS MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:CANYON SPRINGS MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FAHEEM
Authorized Official - Middle Name:M
Authorized Official - Last Name:JUKAKU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-486-5610
Mailing Address - Street 1:26520 CACTUS AVE
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92555-3927
Mailing Address - Country:US
Mailing Address - Phone:951-486-5610
Mailing Address - Fax:951-486-5620
Practice Address - Street 1:26520 CACTUS AVE RM B2018
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92555-3927
Practice Address - Country:US
Practice Address - Phone:951-486-5610
Practice Address - Fax:951-486-5620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0088740Medicaid
CAGR0088740Medicaid