Healthcare Provider Details

I. General information

NPI: 1205224417
Provider Name (Legal Business Name): MISSION GROVE MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2014
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

191 E ALESSANDRO BLVD # 9A
RIVERSIDE CA
92508-5095
US

IV. Provider business mailing address

191 E ALESSANDRO BLVD # 9A
RIVERSIDE CA
92508-5095
US

V. Phone/Fax

Practice location:
  • Phone: 951-780-3300
  • Fax: 951-780-3303
Mailing address:
  • Phone: 951-780-3300
  • Fax: 951-780-3303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License NumberA39116
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JEAN LACOMBE
Title or Position: AO
Credential:
Phone: 951-780-3300