Provider Demographics
NPI:1912394255
Name:JOSEPH M MOLINA MD PROFESSIONAL CORPORATION SOUTHERN CALIFORNIA
Entity Type:Organization
Organization Name:JOSEPH M MOLINA MD PROFESSIONAL CORPORATION SOUTHERN CALIFORNIA
Other - Org Name:MOLINA FONTANA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:KENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:HEINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-964-1506
Mailing Address - Street 1:5626 OBERLIN DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-1705
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17500 FOOTHILL BLVD
Practice Address - Street 2:SUITE A2
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-3736
Practice Address - Country:US
Practice Address - Phone:909-428-0170
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEDVANTX, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-04-24
Last Update Date:2015-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG45659332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site