Provider Demographics
NPI:1215358502
Name:SPA M MEDICAL CORPORATION
Entity Type:Organization
Organization Name:SPA M MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:K
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:951-694-4200
Mailing Address - Street 1:27520 YNEZ RD
Mailing Address - Street 2:SUITE C5
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92591-4650
Mailing Address - Country:US
Mailing Address - Phone:951-694-4200
Mailing Address - Fax:951-694-4244
Practice Address - Street 1:27520 YNEZ RD
Practice Address - Street 2:SUITE C5
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92591-4650
Practice Address - Country:US
Practice Address - Phone:951-694-4200
Practice Address - Fax:951-694-4244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-03
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A8981261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care