Provider Demographics
NPI:1447793088
Name:ORCHID MEDICAL GROUP
Entity Type:Organization
Organization Name:ORCHID MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARLISE
Authorized Official - Middle Name:
Authorized Official - Last Name:NEGRETTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-793-5511
Mailing Address - Street 1:5917 SPEYSIDE RD
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-8475
Mailing Address - Country:US
Mailing Address - Phone:951-323-1907
Mailing Address - Fax:
Practice Address - Street 1:395 TERRACINA BLVD
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-4849
Practice Address - Country:US
Practice Address - Phone:951-323-1907
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-30
Last Update Date:2017-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA064957174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty