Healthcare Provider Details

I. General information

NPI: 1295125318
Provider Name (Legal Business Name): TIBBETTS MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2015
Last Update Date: 01/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3722 TIBBETTS ST
RIVERSIDE CA
92506-2605
US

IV. Provider business mailing address

9041 MAGNOLIA AVE SUITE 107
RIVERSIDE CA
92503-3900
US

V. Phone/Fax

Practice location:
  • Phone: 951-784-3770
  • Fax:
Mailing address:
  • Phone: 951-353-1021
  • Fax: 951-710-1964

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER J CHAPMAN
Title or Position: ADMINISTRATOR
Credential:
Phone: 951-353-1021