Provider Demographics
NPI:1770685968
Name:NEUROCENTER MEDICAL CLINIC INC
Entity Type:Organization
Organization Name:NEUROCENTER MEDICAL CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAJA
Authorized Official - Middle Name:B
Authorized Official - Last Name:BOUTROS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-696-1818
Mailing Address - Street 1:P.O BOX 2770
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92593-2770
Mailing Address - Country:US
Mailing Address - Phone:951-696-1818
Mailing Address - Fax:951-696-2939
Practice Address - Street 1:25485 MEDICAL CENTER DR
Practice Address - Street 2:#108
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-6900
Practice Address - Country:US
Practice Address - Phone:951-696-1818
Practice Address - Fax:951-696-2939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-01
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAF439492084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA930048312OtherRAILROAD MEDICARE #
CAZZZ094462OtherBLUE CROSS GROUP ID #
CAGR0091910Medicaid
CA90050380OtherPACIFICARE ID#
CA0693834OtherMEDICAL ID #
CAF43949Medicare UPIN
CA90050380OtherPACIFICARE ID#