Basic Information
| Provider Information | |||||||||
| NPI: | 1033309372 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MINUTECLINIC DIAGNOSTIC MEDICAL GROUP OF CALIFORNIA, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 772 | ||||||||
| Address2: | PAYOR ENROLLMENT-MC 2295 | ||||||||
| City: | WOONSOCKET | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028950784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8663892727 | ||||||||
| FaxNumber: | 4014063539 | ||||||||
| Practice Location | |||||||||
| Address1: | 19353 VICTORY BLVD | ||||||||
| Address2: | |||||||||
| City: | TARZANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913356302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8663892727 | ||||||||
| FaxNumber: | 4014063539 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2007 | ||||||||
| LastUpdateDate: | 02/04/2022 | ||||||||
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| AuthorizedOfficialLastName: | PINCINCE | ||||||||
| AuthorizedOfficialFirstName: | DEBORAH | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 4017703813 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 363LF0000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | DO3845 | 01 | CA | MEDICARE RAILROAD | OTHER |