Provider Demographics
NPI:1720256415
Name:MEMORIAL RESEARCH MEDICAL CLINIC
Entity Type:Organization
Organization Name:MEMORIAL RESEARCH MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MED DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:M
Authorized Official - Last Name:NEUTEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-550-9990
Mailing Address - Street 1:14351 MYFORD RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-7045
Mailing Address - Country:US
Mailing Address - Phone:714-550-9990
Mailing Address - Fax:714-210-7087
Practice Address - Street 1:14351 MYFORD RD
Practice Address - Street 2:SUITE B
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-7045
Practice Address - Country:US
Practice Address - Phone:714-550-9990
Practice Address - Fax:714-210-7087
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-14
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA50551207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA50551OtherLICENSE NO
CAA50551OtherLICENSE NO