Healthcare Provider Details

I. General information

NPI: 1215107354
Provider Name (Legal Business Name): ORTHOPAEDIC MEDICAL GROUP OF RIVERSIDE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2008
Last Update Date: 03/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6850 BROCKTON AVE SUITE 212
RIVERSIDE CA
92506-3808
US

IV. Provider business mailing address

6850 BROCKTON AVE SUITE 212
RIVERSIDE CA
92506-3808
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPSY 11922
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberA69385
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

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