Healthcare Provider Details

I. General information

NPI: 1417885468
Provider Name (Legal Business Name): SOCAL SPECIALTY CARE MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2026
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 W STATE ST STE 3D
REDLANDS CA
92373-4653
US

IV. Provider business mailing address

308 W STATE ST STE 3D
REDLANDS CA
92373-4653
US

V. Phone/Fax

Practice location:
  • Phone: 909-577-1124
  • Fax:
Mailing address:
  • Phone: 909-577-1124
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LANDON S EHTESHAMZADEH
Title or Position: VICE PRESIDENT
Credential:
Phone: 909-577-1124