Provider Demographics
NPI:1376632281
Name:SOUTHERN CALIFORNIA PRIMARY CARE MEDICAL GROUP, INC
Entity type:Organization
Organization Name:SOUTHERN CALIFORNIA PRIMARY CARE MEDICAL GROUP, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAMMAD
Authorized Official - Middle Name:R
Authorized Official - Last Name:DANESH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-244-3500
Mailing Address - Street 1:31581 CANYON ESTATES DR
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92532-0424
Mailing Address - Country:US
Mailing Address - Phone:951-244-3500
Mailing Address - Fax:951-244-3535
Practice Address - Street 1:31581 CANYON ESTATES DR
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92532-0424
Practice Address - Country:US
Practice Address - Phone:951-244-3500
Practice Address - Fax:951-244-3535
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2025-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F22638Medicare UPIN