Healthcare Provider Details

I. General information

NPI: 1669545778
Provider Name (Legal Business Name): SOUTHWEST TRAUMA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25500 MEDICAL CENTER DR
MURRIETA CA
92562-5965
US

IV. Provider business mailing address

25470 MEDICAL CENTER DR 206
MURRIETA CA
92562-4900
US

V. Phone/Fax

Practice location:
  • Phone: 951-696-6000
  • Fax: 951-296-6149
Mailing address:
  • Phone: 951-973-7380
  • Fax: 951-973-7389

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. FETUS DADA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 951-973-7380