Healthcare Provider Details

I. General information

NPI: 1689680001
Provider Name (Legal Business Name): MEMORIAL FAMILY MEDICINE MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 08/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 E SPRING ST #1
LONG BEACH CA
90806-1625
US

IV. Provider business mailing address

450 E SPRING ST #1
LONG BEACH CA
90806-1625
US

V. Phone/Fax

Practice location:
  • Phone: 562-933-0050
  • Fax: 562-933-0079
Mailing address:
  • Phone: 562-933-0050
  • Fax: 562-933-0079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. SUSAN Y MELVIN
Title or Position: CEO
Credential: DO
Phone: 562-933-0055