Provider Demographics
NPI:1942414032
Name:SAN CLEMENTE DIAGNOSTIC MEDICAL CLINIC
Entity Type:Organization
Organization Name:SAN CLEMENTE DIAGNOSTIC MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ARTURO
Authorized Official - Middle Name:
Authorized Official - Last Name:FONTANES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-493-0811
Mailing Address - Street 1:665 CAMINO DE LOS MARES STE 305
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-2841
Mailing Address - Country:US
Mailing Address - Phone:949-661-1215
Mailing Address - Fax:
Practice Address - Street 1:665 CAMINO DE LOS MARES STE 305
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-2841
Practice Address - Country:US
Practice Address - Phone:949-661-1215
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC30059174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWC30059BMedicare ID - Type Unspecified
CAWA24788BMedicare ID - Type Unspecified