Provider Demographics
NPI:1235365701
Name:KEYSTONE MEDICAL GROUP
Entity Type:Organization
Organization Name:KEYSTONE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:JORDAN
Authorized Official - Last Name:WEESSIES
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:951-682-4404
Mailing Address - Street 1:4843 ARLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92504-2760
Mailing Address - Country:US
Mailing Address - Phone:951-682-4404
Mailing Address - Fax:951-682-4406
Practice Address - Street 1:4843 ARLINGTON AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92504-2760
Practice Address - Country:US
Practice Address - Phone:951-682-4404
Practice Address - Fax:951-682-4406
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-10
Last Update Date:2009-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC24932111N00000X
CAC413972081N0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081N0008XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationNeuromuscular MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty