Provider Demographics
NPI:1922329127
Name:MEMORIAL FAMILY MEDICINE MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:MEMORIAL FAMILY MEDICINE MEDICAL GROUP, INC.
Other - Org Name:SAN CLEMENTE FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:YVONNE
Authorized Official - Last Name:MELVIN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:562-933-0053
Mailing Address - Street 1:1300 AVENIDA VISTA HERMOSA
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-6315
Mailing Address - Country:US
Mailing Address - Phone:949-452-3199
Mailing Address - Fax:949-218-6866
Practice Address - Street 1:450 E SPRING ST
Practice Address - Street 2:SUITE 1
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-1625
Practice Address - Country:US
Practice Address - Phone:562-933-0053
Practice Address - Fax:562-933-0079
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEMORIAL FAMILY MEDICINE MEDICAL GROUP, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-06-22
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A5075207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0071000Medicaid