=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164956785
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTH BRISTOL INJURY AND FAMILY MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/20/2017
-----------------------------------------------------
Last Update Date | 04/20/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5430 ARLINGTON AVE 1415 N. BROADWAY AVE. SANTA ANA, CA. 92706
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92504-2505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-689-2955
-----------------------------------------------------
Fax | 951-689-2477
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5430 ARLINGTON AVE
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92504-2505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-689-2955
-----------------------------------------------------
Fax | 951-689-2477
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINIC MANAGEMENT
-----------------------------------------------------
Name | ANDREW G PEREZ
-----------------------------------------------------
Credential | JD
-----------------------------------------------------
Telephone | 909-581-5472
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 95006356
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------