Provider Demographics
NPI:1689117137
Name:SAN LUIS REY MEDICAL GROUP
Entity Type:Organization
Organization Name:SAN LUIS REY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:S
Authorized Official - Last Name:FRUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-240-7200
Mailing Address - Street 1:6400 OAK CYN
Mailing Address - Street 2:SUITE 200
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-5203
Mailing Address - Country:US
Mailing Address - Phone:858-229-6156
Mailing Address - Fax:
Practice Address - Street 1:4002 VISTA WAY
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92056-4506
Practice Address - Country:US
Practice Address - Phone:858-229-6156
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-30
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative MedicineGroup - Multi-Specialty
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative MedicineGroup - Multi-Specialty