Provider Demographics
NPI:1477860187
Name:MOLINA HEALTHCARE OF CALIFORNIA
Entity Type:Organization
Organization Name:MOLINA HEALTHCARE OF CALIFORNIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP CLINIC OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CALDERON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-491-7074
Mailing Address - Street 1:200 OCEANGATE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-4317
Mailing Address - Country:US
Mailing Address - Phone:562-499-6191
Mailing Address - Fax:562-499-6171
Practice Address - Street 1:170 EAST HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-3658
Practice Address - Country:US
Practice Address - Phone:909-886-9073
Practice Address - Fax:909-881-3814
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-02
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ42490ZMedicare PIN