=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063279651
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHERN CALIFORNIA PERMANENTE MEDICAL GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/01/2024
-----------------------------------------------------
Last Update Date | 09/30/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3951 VAN BUREN BLVD
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92503-3620
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-862-4295
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3951 VAN BUREN BLVD
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92503-3620
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-883-0119
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DEPARTMENT ADMINISTRATOR
-----------------------------------------------------
Name | MADONNA HOLBROOK-LOWE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 951-233-0023
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133V00000X
-----------------------------------------------------
Taxonomy Name | Registered Dietitian
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NULL
-----------------------------------------------------