Provider Demographics
NPI:1619000775
Name:ANZA COMMUNITY MEDICAL CENTER
Entity Type:Organization
Organization Name:ANZA COMMUNITY MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:YUJUNG
Authorized Official - Last Name:YUN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:951-566-6778
Mailing Address - Street 1:PO BOX 391487
Mailing Address - Street 2:
Mailing Address - City:ANZA
Mailing Address - State:CA
Mailing Address - Zip Code:92539-1487
Mailing Address - Country:US
Mailing Address - Phone:951-694-8549
Mailing Address - Fax:951-694-0249
Practice Address - Street 1:56480 HIGHWAY 371
Practice Address - Street 2:
Practice Address - City:ANZA
Practice Address - State:CA
Practice Address - Zip Code:92539
Practice Address - Country:US
Practice Address - Phone:951-694-8549
Practice Address - Fax:951-694-0249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A8759261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX87590Medicaid
CAH78016Medicare UPIN
CAZZZ02419ZMedicare ID - Type UnspecifiedGROUP ID
CA020A87591Medicare ID - Type Unspecified