Healthcare Provider Details

I. General information

NPI: 1477622587
Provider Name (Legal Business Name): CROWN SURGERY MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 02/17/2020
Certification Date: 02/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25470 MEDICAL CENTER DR SUITE 203
MURRIETA CA
92562-4900
US

IV. Provider business mailing address

25470 MEDICAL CENTER DR SUITE 203
MURRIETA CA
92562-4900
US

V. Phone/Fax

Practice location:
  • Phone: 951-973-7290
  • Fax: 951-973-7299
Mailing address:
  • Phone: 951-973-7290
  • Fax: 951-973-7299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. FETUS DADA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 951-973-7290