Healthcare Provider Details

I. General information

NPI: 1528100187
Provider Name (Legal Business Name): MEMORIALCARE MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 06/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31001 RANCHO VIEJO RD SUITE 200
SAN JUAN CAPISTRANO CA
92675
US

IV. Provider business mailing address

5626 OBERLIN DR SUITE 110
SAN DIEGO CA
92121-1705
US

V. Phone/Fax

Practice location:
  • Phone: 949-661-9600
  • Fax:
Mailing address:
  • Phone: 858-625-2990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License NumberA38178
License Number StateCA

VIII. Authorized Official

Name: KENNY HEINE
Title or Position: VP OF OPERATIONS
Credential:
Phone: 858-625-2990