Provider Demographics
NPI:1598027112
Name:GREEN RIVER MEDICAL & AESTHETIC CENTRE INC.
Entity Type:Organization
Organization Name:GREEN RIVER MEDICAL & AESTHETIC CENTRE INC.
Other - Org Name:FAMILY & AESTHETIC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:C.O.O
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:B
Authorized Official - Last Name:MANTELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-735-5570
Mailing Address - Street 1:PO BOX 18706
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92817-8706
Mailing Address - Country:US
Mailing Address - Phone:951-735-5570
Mailing Address - Fax:951-735-5572
Practice Address - Street 1:2791 GREEN RIVER #103
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92882-7426
Practice Address - Country:US
Practice Address - Phone:951-735-5570
Practice Address - Fax:951-735-5572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-11
Last Update Date:2014-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANPF20032261QA0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0005XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Family Planning Facility