Provider Demographics
NPI:1659677433
Name:FACULTY MEDICAL GROUP OF LLUSM
Entity Type:Organization
Organization Name:FACULTY MEDICAL GROUP OF LLUSM
Other - Org Name:FMG-ED MURRIETA
Other - Org Type:Other Name
Authorized Official - Title/Position:PROVIDER ENROLLMENT REP
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-558-3289
Mailing Address - Street 1:11165 MOUNTAIN VIEW AVE
Mailing Address - Street 2:STE 228
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3866
Mailing Address - Country:US
Mailing Address - Phone:909-558-3111
Mailing Address - Fax:
Practice Address - Street 1:28062 BAXTER ROAD
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92563
Practice Address - Country:US
Practice Address - Phone:909-558-3111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FACULTY MEDICAL GROUP OF LLUSM IND
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-01-27
Last Update Date:2011-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports MedicineGroup - Multi-Specialty