Provider Demographics
NPI:1871648303
Name:MISSION COMMUNITY MEDICAL CORPORATION
Entity Type:Organization
Organization Name:MISSION COMMUNITY MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SOHRAB
Authorized Official - Middle Name:
Authorized Official - Last Name:SALAMATIPOUR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-628-8888
Mailing Address - Street 1:775 N TUSTIN ST
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92867-7128
Mailing Address - Country:US
Mailing Address - Phone:714-628-8888
Mailing Address - Fax:714-538-2124
Practice Address - Street 1:775 N TUSTIN ST
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92867-7128
Practice Address - Country:US
Practice Address - Phone:714-628-8888
Practice Address - Fax:714-538-2124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA63781174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0089700Medicaid
CAGR0089700Medicaid