Provider Demographics
NPI:1295152668
Name:COMMUNITY OUTREACH MEDICAL SERVICES
Entity type:Organization
Organization Name:COMMUNITY OUTREACH MEDICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO / CMO
Authorized Official - Prefix:DR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:NAVA
Authorized Official - Last Name:FLORES
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:657-600-9077
Mailing Address - Street 1:1200 N TUSTIN AVE
Mailing Address - Street 2:SUITE 130
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92705
Mailing Address - Country:US
Mailing Address - Phone:657-600-9077
Mailing Address - Fax:657-600-9067
Practice Address - Street 1:1200 N TUSTIN AVE
Practice Address - Street 2:SUITE 130
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-3508
Practice Address - Country:US
Practice Address - Phone:657-600-9077
Practice Address - Fax:657-600-9067
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-24
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGM702AMedicare PIN