Healthcare Provider Details

I. General information

NPI: 1124519855
Provider Name (Legal Business Name): LIZARRAGA MEDICAL CLINIC INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2018
Last Update Date: 07/15/2021
Certification Date: 05/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

895 W VALLEY BLVD
COLTON CA
92324-2001
US

IV. Provider business mailing address

2090 S EUCLID ST STE 104
ANAHEIM CA
92802-3141
US

V. Phone/Fax

Practice location:
  • Phone: 909-824-3389
  • Fax:
Mailing address:
  • Phone: 714-539-2200
  • Fax: 714-539-2277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JUAN FERNANDO LIZARRAGA
Title or Position: MD/OWNER
Credential: M.D.
Phone: 562-405-6299