Provider Demographics
NPI:1770653289
Name:MISSION VIEJO MEDICAL CLINIC
Entity Type:Organization
Organization Name:MISSION VIEJO MEDICAL CLINIC
Other - Org Name:LAGUNA NIGUEL FAMILY MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:FRANCIS
Authorized Official - Last Name:LYON
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:949-495-7144
Mailing Address - Street 1:30110 CROWN VALLEY PKWY
Mailing Address - Street 2:
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-2043
Mailing Address - Country:US
Mailing Address - Phone:949-496-3013
Mailing Address - Fax:949-495-0270
Practice Address - Street 1:30110 CROWN VALLEY PKWY
Practice Address - Street 2:
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-2043
Practice Address - Country:US
Practice Address - Phone:949-496-3013
Practice Address - Fax:949-495-0270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2007-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC27618261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C276180Medicaid
CAC27618OtherSTATE LICENSE
CAZZZ12501ZOtherBLUE SHIELD
CAZZZ12501ZOtherBLUE SHIELD
CA00C276180Medicaid