Provider Demographics
NPI:1447396593
Name:SAN MARCOS MEDICAL GROUP INC.
Entity Type:Organization
Organization Name:SAN MARCOS MEDICAL GROUP INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATER
Authorized Official - Prefix:
Authorized Official - First Name:AZER
Authorized Official - Middle Name:
Authorized Official - Last Name:REZK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-376-7715
Mailing Address - Street 1:1574 W BASE LINE ST STE 107
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92411-1736
Mailing Address - Country:US
Mailing Address - Phone:909-386-1880
Mailing Address - Fax:909-386-1882
Practice Address - Street 1:1574 W BASE LINE ST STE 107
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92411-1736
Practice Address - Country:US
Practice Address - Phone:909-386-1880
Practice Address - Fax:909-386-1882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALAB 69268F291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALAB69268FMedicaid