Healthcare Provider Details

I. General information

NPI: 1023314507
Provider Name (Legal Business Name): VALLEY PATHOLOGY MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2011
Last Update Date: 02/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1117 E DEVONSHIRE AVE
HEMET CA
92543-3083
US

IV. Provider business mailing address

PO BOX 10076
VAN NUYS CA
91410-0076
US

V. Phone/Fax

Practice location:
  • Phone: 951-652-2811
  • Fax:
Mailing address:
  • Phone: 805-578-8300
  • Fax: 805-578-3911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number05D2006190
License Number StateCA

VIII. Authorized Official

Name: ALAN MARE
Title or Position: PRESIDENT
Credential: MD
Phone: 951-925-6318