Healthcare Provider Details

I. General information

NPI: 1932434206
Provider Name (Legal Business Name): PACIFIC HEART MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2009
Last Update Date: 01/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25470 MEDICAL CENTER DR SUITE 201
MURRIETA CA
92562-4900
US

IV. Provider business mailing address

1545 W FLORIDA AVE
HEMET CA
92543-3814
US

V. Phone/Fax

Practice location:
  • Phone: 951-698-4433
  • Fax: 951-698-0840
Mailing address:
  • Phone: 951-791-1111
  • Fax: 951-925-3606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number3227680
License Number StateCA

VIII. Authorized Official

Name: FESTUS DADA
Title or Position: OWNER
Credential: M.D.
Phone: 951-791-1111