Healthcare Provider Details

I. General information

NPI: 1124050620
Provider Name (Legal Business Name): ORTHOPAEDIC MEDICAL GROUP OF RIVERSIDE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 06/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6860 BROCKTON AVE SUITE 7
RIVERSIDE CA
92506-3816
US

IV. Provider business mailing address

6850 BROCKTON AVE SUITE 212
RIVERSIDE CA
92506-3808
US

V. Phone/Fax

Practice location:
  • Phone: 951-369-0860
  • Fax: 951-774-4623
Mailing address:
  • Phone: 951-774-4611
  • Fax: 951-276-3597

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY11922
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberPT29088
License Number StateCA

VIII. Authorized Official

Name: MR. JUAN D. GUAJARDO
Title or Position: CEO
Credential:
Phone: 951-774-4611