Healthcare Provider Details

I. General information

NPI: 1164956785
Provider Name (Legal Business Name): NORTH BRISTOL INJURY AND FAMILY MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2017
Last Update Date: 04/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5430 ARLINGTON AVE 1415 N. BROADWAY AVE. SANTA ANA, CA. 92706
RIVERSIDE CA
92504-2505
US

IV. Provider business mailing address

5430 ARLINGTON AVE
RIVERSIDE CA
92504-2505
US

V. Phone/Fax

Practice location:
  • Phone: 951-689-2955
  • Fax: 951-689-2477
Mailing address:
  • Phone: 951-689-2955
  • Fax: 951-689-2477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95006356
License Number StateCA

VIII. Authorized Official

Name: ANDREW G PEREZ
Title or Position: CLINIC MANAGEMENT
Credential: JD
Phone: 909-581-5472