Healthcare Provider Details

I. General information

NPI: 1194930420
Provider Name (Legal Business Name): MODERN CONCEPTS MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 BELLEFONTAINE ST 404
PASADENA CA
91105-3132
US

IV. Provider business mailing address

PO BOX 640
MONTEBELLO CA
90640-0640
US

V. Phone/Fax

Practice location:
  • Phone: 323-728-6070
  • Fax: 323-728-2912
Mailing address:
  • Phone: 323-728-6070
  • Fax: 323-728-2912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: MARGARET HERRERA
Title or Position: PRESIDENT
Credential: MD
Phone: 323-728-6070