Healthcare Provider Details

I. General information

NPI: 1457300436
Provider Name (Legal Business Name): MISSION SURGICAL CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 12/28/2021
Certification Date: 12/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7300 MAGNOLIA AVE
RIVERSIDE CA
92504-3849
US

IV. Provider business mailing address

PO BOX 2828
CORONA CA
92878-2828
US

V. Phone/Fax

Practice location:
  • Phone: 951-278-8870
  • Fax: 951-278-8913
Mailing address:
  • Phone: 951-278-8870
  • Fax: 951-278-8913

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number20A10803
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberG75730
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number20A9434
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA16804
License Number StateCA
# 5
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberG56529
License Number StateCA

VIII. Authorized Official

Name: DR. MICHAEL S. CHIN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 951-278-8870