Provider Demographics
NPI:1437230687
Name:RIVERSIDE REGIONAL PEDIATRIC MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:RIVERSIDE REGIONAL PEDIATRIC MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GUILLERMO
Authorized Official - Middle Name:
Authorized Official - Last Name:VALENZUELA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-580-6320
Mailing Address - Street 1:12712 HEACOCK ST STE 3
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-3037
Mailing Address - Country:US
Mailing Address - Phone:951-601-6802
Mailing Address - Fax:951-601-9302
Practice Address - Street 1:12712 HEACOCK ST STE 3
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-3037
Practice Address - Country:US
Practice Address - Phone:951-601-6802
Practice Address - Fax:951-601-9302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0086161OtherMEDI-CAL PROVIDER NUMBER