Provider Demographics
NPI:1417900788
Name:EASTERN VENTURA MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:EASTERN VENTURA MEDICAL GROUP, INC.
Other - Org Name:MED CENTER MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DENICE
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSCIGNO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-583-5555
Mailing Address - Street 1:1980 SEQUOIA AVE
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93063-3167
Mailing Address - Country:US
Mailing Address - Phone:805-583-5555
Mailing Address - Fax:805-583-5637
Practice Address - Street 1:1980 SEQUOIA AVE
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93063-3167
Practice Address - Country:US
Practice Address - Phone:805-583-5555
Practice Address - Fax:805-583-5554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW10781Medicare ID - Type UnspecifiedPROVIDER NUMBER