Provider Demographics
NPI:1629442785
Name:MORNING STAR FAMILY MEDICINE PC
Entity Type:Organization
Organization Name:MORNING STAR FAMILY MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:FUENTES
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:909-931-0446
Mailing Address - Street 1:99 N SAN ANTONIO AVE
Mailing Address - Street 2:SUITE 330
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4575
Mailing Address - Country:US
Mailing Address - Phone:909-931-0446
Mailing Address - Fax:
Practice Address - Street 1:99 N SAN ANTONIO AVE
Practice Address - Street 2:SUITE 330
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4575
Practice Address - Country:US
Practice Address - Phone:909-931-0446
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-30
Last Update Date:2015-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A12006291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory