Provider Demographics
NPI:1972646784
Name:YUCAIPA FAMILY MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:YUCAIPA FAMILY MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR 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:858-625-2990
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 1:34636 COUNTY LINE RD
Practice Address - Street 2:#32
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399-5393
Practice Address - Country:US
Practice Address - Phone:909-795-4440
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEDVANTX, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-14
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6282332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site