Healthcare Provider Details

I. General information

NPI: 1215122213
Provider Name (Legal Business Name): WOODCREST MEDICAL CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2007
Last Update Date: 09/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9041 MAGNOLIA AVE SUITE 105B
RIVERSIDE CA
92503-3900
US

IV. Provider business mailing address

9041 MAGNOLIA AVE SUITE 105B
RIVERSIDE CA
92503-3900
US

V. Phone/Fax

Practice location:
  • Phone: 951-351-7726
  • Fax: 951-351-7730
Mailing address:
  • Phone: 951-351-7726
  • Fax: 951-351-7730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA40030
License Number StateCA

VIII. Authorized Official

Name: PETER CONRAD PAUL
Title or Position: PRESIDENT
Credential: M.D
Phone: 951-351-7726