Healthcare Provider Details

I. General information

NPI: 1043508559
Provider Name (Legal Business Name): SOUTHERN CALIFORNIA PRIMARY MEDICAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2011
Last Update Date: 08/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19341 BEAR VALLEY RD STE 101
APPLE VALLEY CA
92308
US

IV. Provider business mailing address

8237 ROCHESTER AVE STE 110
RANCHO CUCAMONGA CA
91730-0717
US

V. Phone/Fax

Practice location:
  • Phone: 760-810-7778
  • Fax: 760-810-7780
Mailing address:
  • Phone: 909-477-3310
  • Fax: 909-477-3320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberA91216
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberA91216
License Number StateCA

VIII. Authorized Official

Name: ASHISH MALHOTRA
Title or Position: OWNER
Credential: M.D.
Phone: 760-810-7778