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General NPI Number Information
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NPI Number | 1073669404
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Entity Type | Organization
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Legal Business Name | CANYON SPRINGS MEDICAL GROUP, INC.
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Dates
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Enumeration Date | 01/26/2007
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Last Update Date | 04/23/2018
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Provider Practice Location Address
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Address Line | 26520 CACTUS AVE RM B2018
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City | MORENO VALLEY
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State | CA
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Zip | 92555-3927
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Country | US
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Telephone | 951-486-5610
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Fax | 951-486-5620
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Provider Business Mailing Address
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Address Line | 26520 CACTUS AVE
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City | MORENO VALLEY
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State | CA
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Zip | 92555-3927
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Country | US
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Telephone | 951-486-5610
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Fax | 951-486-5620
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Authorized Official
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Title or Position | PRESIDENT
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Name | FAHEEM M. JUKAKU
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Credential | M.D.
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Telephone | 951-486-5610
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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