Provider Demographics
NPI:1225186505
Name:JUSTINA M. BRESENO, M.D., INC.
Entity Type:Organization
Organization Name:JUSTINA M. BRESENO, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTINA
Authorized Official - Middle Name:M
Authorized Official - Last Name:BRESENO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-653-1683
Mailing Address - Street 1:6485 DAY ST STE 103
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-0930
Mailing Address - Country:US
Mailing Address - Phone:951-653-1683
Mailing Address - Fax:951-653-1873
Practice Address - Street 1:6485 DAY ST STE 103
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-0930
Practice Address - Country:US
Practice Address - Phone:951-653-1683
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA50599261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF58808Medicare UPIN