Provider Demographics
NPI:1942485610
Name:ANZA COMMUNITY MEDICAL CENTER CORP
Entity Type:Organization
Organization Name:ANZA COMMUNITY MEDICAL CENTER CORP
Other - Org Name:ANZA COMMUNITY MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:YUJUNG
Authorized Official - Last Name:YUN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:951-595-5589
Mailing Address - Street 1:56480 HIGHWAY 371
Mailing Address - Street 2:P.O. BOX 391313
Mailing Address - City:ANZA
Mailing Address - State:CA
Mailing Address - Zip Code:92539
Mailing Address - Country:US
Mailing Address - Phone:951-763-2626
Mailing Address - Fax:951-763-5353
Practice Address - Street 1:56480 HIGHWAY 371
Practice Address - Street 2:
Practice Address - City:ANZA
Practice Address - State:CA
Practice Address - Zip Code:92539
Practice Address - Country:US
Practice Address - Phone:951-763-2626
Practice Address - Fax:951-763-5353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-31
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A8759261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX87590Medicaid
CA00AX87590Medicaid
CA020A87591Medicare PIN