Healthcare Provider Details

I. General information

NPI: 1003846486
Provider Name (Legal Business Name): HEALTHCARE PROVIDERS OF CALIFORNIA MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

342 W SAN YSIDRO BLVD #F
SAN YSIDRO CA
92173-2495
US

IV. Provider business mailing address

24425 WOOLSEY CANYON RD #11
CANOGA PARK CA
91304-1131
US

V. Phone/Fax

Practice location:
  • Phone: 619-662-3880
  • Fax: 619-662-2942
Mailing address:
  • Phone: 818-713-1115
  • Fax: 818-713-1116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA51621
License Number StateCA

VIII. Authorized Official

Name: DR. EDWARD JOHN GIAQUINTO JR.
Title or Position: PRESIDENT
Credential: PH.D.
Phone: 818-421-2799