Provider Demographics
NPI:1689717613
Name:SAN MARCOS MEDICAL GROUP
Entity Type:Organization
Organization Name:SAN MARCOS MEDICAL GROUP
Other - Org Name:METROPOLITAN INDUSTRIAL MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:AZER
Authorized Official - Middle Name:
Authorized Official - Last Name:REZK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-376-7715
Mailing Address - Street 1:10444 LIVEOAK AVE.
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92337-7219
Mailing Address - Country:US
Mailing Address - Phone:909-770-8293
Mailing Address - Fax:909-770-8298
Practice Address - Street 1:10444 LIVEOAK AVE.
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92337-7219
Practice Address - Country:US
Practice Address - Phone:909-770-8293
Practice Address - Fax:909-770-8298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA040591261QX0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA045091OtherMEDICAL LISCENCE