Provider Demographics
NPI:1760802805
Name:TEMECULA VALLEY FAMILY MEDICAL GROUP
Entity Type:Organization
Organization Name:TEMECULA VALLEY FAMILY MEDICAL GROUP
Other - Org Name:TEMECULA VALLEY FAMILY MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EARL
Authorized Official - Middle Name:B
Authorized Official - Last Name:QUIJADA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-764-9673
Mailing Address - Street 1:27475 YNEZ ROAD
Mailing Address - Street 2:SUITE 313
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92591
Mailing Address - Country:US
Mailing Address - Phone:951-764-9673
Mailing Address - Fax:909-941-6974
Practice Address - Street 1:9380 7TH STREET
Practice Address - Street 2:SUITE H
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730
Practice Address - Country:US
Practice Address - Phone:909-484-2865
Practice Address - Fax:909-941-6974
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-16
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA60997208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A609970Medicaid
CA00A609971Medicare PIN
CAG78868Medicare UPIN