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General NPI Number Information
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NPI Number | 1205193521
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Entity Type | Individual
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Provider Name | NOEL NEPOMUCENO JR. M.D.
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Gender | Male
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Dates
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Enumeration Date | 04/12/2012
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Last Update Date | 12/01/2021
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Provider Practice Location Address
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Address Line | 36450 INLAND VALLEY DR SOUTHERN CALIFORNIA PERMANENTE MEDICAL GROUP
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City | WILDOMAR
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State | CA
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Zip | 92595-9583
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Country | US
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Telephone | 951-600-3476
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Fax |
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Provider Business Mailing Address
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Address Line | 10976 RAGSDALE RD
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City | LOMA LINDA
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State | CA
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Zip | 92354-6545
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Country | US
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Telephone | 909-900-7831
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QS0010X
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Taxonomy Name | Sports Medicine (Family Medicine) Physician
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License Number | A122221
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License Number State | CA
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