Provider Demographics
NPI:1740815166
Name:MORENO VALLEY MEDICAL GROUP, INC
Entity type:Organization
Organization Name:MORENO VALLEY MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:P
Authorized Official - Last Name:RICHARDS
Authorized Official - Suffix:SR
Authorized Official - Credentials:CMAIII
Authorized Official - Phone:951-242-9595
Mailing Address - Street 1:24490 SUNNYMEAD BLVD STE 117
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-7764
Mailing Address - Country:US
Mailing Address - Phone:951-242-9595
Mailing Address - Fax:
Practice Address - Street 1:24490 SUNNYMEAD BLVD
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-7734
Practice Address - Country:US
Practice Address - Phone:951-242-9595
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A703100Medicaid
BI6620923OtherDEA CERTIFICATE