Healthcare Provider Details

I. General information

NPI: 1992950703
Provider Name (Legal Business Name): TOTAL CARE FAMILY MEDICAL CENTER OF LAKE ELSINORE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2008
Last Update Date: 11/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 DIAMOND DRIVE SUITE 105
LAKE ELSINORE CA
92530
US

IV. Provider business mailing address

425 DIAMOND DRIVE SUITE 105
LAKE ELSINORE CA
92530
US

V. Phone/Fax

Practice location:
  • Phone: 951-674-8779
  • Fax:
Mailing address:
  • Phone: 951-674-8779
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG72993
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. NA'IMAH D POWELL
Title or Position: OWNER
Credential: M.D.
Phone: 951-674-8779