Provider Demographics
NPI:1083851703
Name:PERRIS VALLEY MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:PERRIS VALLEY MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:VILLANUEVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-657-0544
Mailing Address - Street 1:126 AVOCADO AVE
Mailing Address - Street 2:SUITE 207
Mailing Address - City:PERRIS
Mailing Address - State:CA
Mailing Address - Zip Code:92571-2605
Mailing Address - Country:US
Mailing Address - Phone:951-657-0544
Mailing Address - Fax:951-657-9644
Practice Address - Street 1:126 AVOCADO AVE
Practice Address - Street 2:SUITE 207
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92571-2605
Practice Address - Country:US
Practice Address - Phone:951-657-0544
Practice Address - Fax:951-657-9644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-16
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6023207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE90354Medicaid
CA020A60230Medicare PIN