Healthcare Provider Details

I. General information

NPI: 1083017834
Provider Name (Legal Business Name): JOSEPH M MOLINA MD PROFESSIONAL CORPORATION SOUTHERN CALIFORNIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2014
Last Update Date: 12/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 E ARTESIA BLVD
LONG BEACH CA
90805-1476
US

IV. Provider business mailing address

9276 SCRANTON RD SUITE 100
SAN DIEGO CA
92121-7701
US

V. Phone/Fax

Practice location:
  • Phone: 562-423-3383
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number20A10903
License Number StateCA

VIII. Authorized Official

Name: KENNY HEINE
Title or Position: VP OF OPERATIONS
Credential:
Phone: 858-964-1506