Provider Demographics
NPI:1376310516
Name:PROFESSIONAL MEDICAL GROUP INC
Entity Type:Organization
Organization Name:PROFESSIONAL MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RAFAEL
Authorized Official - Middle Name:ARTURO
Authorized Official - Last Name:PENUNURI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-626-4997
Mailing Address - Street 1:505 N TUSTIN AVE STE 190
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-3777
Mailing Address - Country:US
Mailing Address - Phone:310-626-4997
Mailing Address - Fax:310-626-4677
Practice Address - Street 1:20054 HAWTHORNE BLVD
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-1518
Practice Address - Country:US
Practice Address - Phone:310-626-4997
Practice Address - Fax:310-626-4677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-07
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care