Healthcare Provider Details

I. General information

NPI: 1609299536
Provider Name (Legal Business Name): SPA M MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2014
Last Update Date: 01/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27520 YNEZ RD C5
TEMECULA CA
92591-4650
US

IV. Provider business mailing address

27636 YNEZ RD L7 NO 274
TEMECULA CA
92591-5600
US

V. Phone/Fax

Practice location:
  • Phone: 951-694-4200
  • Fax:
Mailing address:
  • Phone: 951-694-4200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A8981
License Number StateCA

VIII. Authorized Official

Name: DR. DENNIS MILLER
Title or Position: OWNER
Credential: MD
Phone: 951-694-4200