Healthcare Provider Details

I. General information

NPI: 1750604948
Provider Name (Legal Business Name): UROLOGY CENTER OF SO CALIF MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2010
Last Update Date: 08/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28078 BAXTER RD #314
MURRIETA CA
92563-1402
US

IV. Provider business mailing address

1820 FULLERTON AVE #260
CORONA CA
92881-3160
US

V. Phone/Fax

Practice location:
  • Phone: 951-677-3000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: BRUCE HOUMAN
Title or Position: CEO
Credential:
Phone: 951-735-2700