Healthcare Provider Details

I. General information

NPI: 1134927858
Provider Name (Legal Business Name): PRO VITAL MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2025
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1245 W 6TH ST UNIT 105
CORONA CA
92882-1870
US

IV. Provider business mailing address

1245 W 6TH ST UNIT 105
CORONA CA
92882-1870
US

V. Phone/Fax

Practice location:
  • Phone: 909-284-9942
  • Fax: 909-284-9943
Mailing address:
  • Phone: 909-284-9942
  • Fax: 909-284-9943

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: MOHAMMAD QUREASHI
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 909-284-9942