Provider Demographics
NPI:1184027112
Name:A.M.PALANCA-CAPISTRANO,M.D.INC.
Entity Type:Organization
Organization Name:A.M.PALANCA-CAPISTRANO,M.D.INC.
Other - Org Name:CAPISTRANO EYE CANTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELITA
Authorized Official - Middle Name:MARQUINEZ
Authorized Official - Last Name:PALANCA-CAPISTRANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-372-9227
Mailing Address - Street 1:19069 VAN BUREN BLVD
Mailing Address - Street 2:114-219
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92508-9169
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13800 HEACOCK ST
Practice Address - Street 2:SUITE C-110
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-3339
Practice Address - Country:US
Practice Address - Phone:951-653-3388
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:A.M.PALANCA-CAPISTRANO,M.D.INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-10-05
Last Update Date:2014-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA91568261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1585438Medicaid