Provider Demographics
NPI:1851625396
Name:LAKE ELSINORE CLINICA MEDICA FAMILIAR A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:LAKE ELSINORE CLINICA MEDICA FAMILIAR A MEDICAL CORPORATION
Other - Org Name:LAKE ELSINORE CLINICA MEDICA FAMILIAR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:OCTAVIO
Authorized Official - Middle Name:
Authorized Official - Last Name:RUIZ-VILLALPANDO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-245-0505
Mailing Address - Street 1:31739 RIVERSIDE DR
Mailing Address - Street 2:SUITE A-1
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-7818
Mailing Address - Country:US
Mailing Address - Phone:951-245-0505
Mailing Address - Fax:951-245-0999
Practice Address - Street 1:31739 RIVERSIDE DR
Practice Address - Street 2:SUITE A-1
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-7818
Practice Address - Country:US
Practice Address - Phone:951-245-0505
Practice Address - Fax:951-245-0999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-01
Last Update Date:2009-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA92039207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty