Provider Demographics
NPI:1497948194
Name:SAN JUAN FAMILY HEALTH URGENT CARE MEDICAL CENTER
Entity Type:Organization
Organization Name:SAN JUAN FAMILY HEALTH URGENT CARE MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:D.O., PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SHAHROKH
Authorized Official - Middle Name:
Authorized Official - Last Name:POORMEHR
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:949-248-9797
Mailing Address - Street 1:32112 CAMINO CAPISTRANO
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN CAPISTRANO
Mailing Address - State:CA
Mailing Address - Zip Code:92675-3717
Mailing Address - Country:US
Mailing Address - Phone:949-248-9797
Mailing Address - Fax:949-388-3336
Practice Address - Street 1:32112 CAMINO CAPISTRANO
Practice Address - Street 2:
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-3717
Practice Address - Country:US
Practice Address - Phone:949-248-9797
Practice Address - Fax:949-388-3336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-25
Last Update Date:2015-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6385207Q00000X, 261Q00000X, 261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX63850Medicaid
CADC5333OtherRAILROAD MEDICARE
CA20A6385OtherSTATE LICENSE
CAZZZ57256ZOtherBLUE SHIELD
CAZZZ57256ZOtherBLUE SHIELD
CA00AX63850Medicaid