Healthcare Provider Details

I. General information

NPI: 1487087136
Provider Name (Legal Business Name): ANESTHESIA MEDICAL GROUP OF IMPERIAL VALLEY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2013
Last Update Date: 06/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 W LEGION RD
BRAWLEY CA
92227-7780
US

IV. Provider business mailing address

PO BOX 7096
STOCKTON CA
95267-0096
US

V. Phone/Fax

Practice location:
  • Phone: 760-351-3288
  • Fax:
Mailing address:
  • Phone: 209-956-7725
  • Fax: 209-956-7733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JAIME ANTHONE ENGLEA-LARRA
Title or Position: GROUP PRESIDENT
Credential: DO
Phone: 760-351-3288