Healthcare Provider Details

I. General information

NPI: 1063279651
Provider Name (Legal Business Name): SOUTHERN CALIFORNIA PERMANENTE MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2024
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3951 VAN BUREN BLVD
RIVERSIDE CA
92503-3620
US

IV. Provider business mailing address

3951 VAN BUREN BLVD
RIVERSIDE CA
92503-3620
US

V. Phone/Fax

Practice location:
  • Phone: 866-862-4295
  • Fax:
Mailing address:
  • Phone: 866-883-0119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number StateNULL

VIII. Authorized Official

Name: MADONNA HOLBROOK-LOWE
Title or Position: DEPARTMENT ADMINISTRATOR
Credential:
Phone: 951-233-0023