Healthcare Provider Details

I. General information

NPI: 1891251849
Provider Name (Legal Business Name): HEACOCK HEALTH MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2019
Last Update Date: 04/15/2025
Certification Date: 04/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24060 FIR AVE STE A
MORENO VALLEY CA
92553-2895
US

IV. Provider business mailing address

24060 FIR AVE STE A
MORENO VALLEY CA
92553-2895
US

V. Phone/Fax

Practice location:
  • Phone: 951-247-8005
  • Fax: 951-247-8007
Mailing address:
  • Phone: 951-247-8005
  • Fax: 951-247-8007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. RAFAEL PENUNURI
Title or Position: MEDICAL DIRECTOR
Credential:
Phone: 951-247-8005