Provider Demographics
NPI:1689166241
Name:PREMIER SENIOR MEDICAL GROUP OF SAN BERNARDINO, INC.
Entity Type:Organization
Organization Name:PREMIER SENIOR MEDICAL GROUP OF SAN BERNARDINO, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:207-217-5451
Mailing Address - Street 1:31938 TEMECULA PKWY STE A237
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92592-6810
Mailing Address - Country:US
Mailing Address - Phone:714-414-3065
Mailing Address - Fax:
Practice Address - Street 1:284 E HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-3706
Practice Address - Country:US
Practice Address - Phone:909-883-1098
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-30
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty