Provider Demographics
NPI:1467635276
Name:CITRUS VALLEY URGENT CARE MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:CITRUS VALLEY URGENT CARE MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:GUY
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:MBA
Authorized Official - Phone:951-737-0910
Mailing Address - Street 1:854 MAGNOLIA AVE
Mailing Address - Street 2:STE. 101
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-3109
Mailing Address - Country:US
Mailing Address - Phone:951-737-0910
Mailing Address - Fax:
Practice Address - Street 1:854 MAGNOLIA AVE
Practice Address - Street 2:STE. 101
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-3109
Practice Address - Country:US
Practice Address - Phone:951-737-0910
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-14
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC2181465207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ23554ZOtherMEDICARE GROUP ID