Healthcare Provider Details

I. General information

NPI: 1689117137
Provider Name (Legal Business Name): SAN LUIS REY MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2016
Last Update Date: 07/19/2024
Certification Date: 07/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27710 JEFFERSON AVE STE 207
TEMECULA CA
92590-4604
US

IV. Provider business mailing address

6400 OAK CYN SUITE 200
IRVINE CA
92618-5203
US

V. Phone/Fax

Practice location:
  • Phone: 833-668-6676
  • Fax: 866-299-8639
Mailing address:
  • Phone: 858-229-6156
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: ANGELA MOUTON
Title or Position: SR VP OPERATIONS
Credential:
Phone: 949-240-7200