Provider Demographics
NPI:1568494078
Name:ORTHOPAEDIC MEDICAL GROUP OF RIVERSIDE, INC.
Entity Type:Organization
Organization Name:ORTHOPAEDIC MEDICAL GROUP OF RIVERSIDE, INC.
Other - Org Name:AIM HI THERAPY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:GUAJARDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-774-4611
Mailing Address - Street 1:6850 BROCKTON AVE
Mailing Address - Street 2:SUITE 212
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-3808
Mailing Address - Country:US
Mailing Address - Phone:951-774-4611
Mailing Address - Fax:951-276-3597
Practice Address - Street 1:399 E HIGHLAND AVE
Practice Address - Street 2:SUITE 409
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-3808
Practice Address - Country:US
Practice Address - Phone:909-881-8612
Practice Address - Fax:909-881-8372
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0393620001Medicare NSC
CAZZZ40607ZMedicare PIN