=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205224417
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MISSION GROVE MEDICAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/23/2014
-----------------------------------------------------
Last Update Date | 03/20/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 191 E. ALESSANDRO BLVD #9A
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92508-5095
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-780-3300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 191 E ALESSANDRO BLVD # 9A
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92508-5095
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-780-3300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AO
-----------------------------------------------------
Name | JEAN LACOMBE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 951-780-3300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QU0200X
-----------------------------------------------------
Taxonomy Name | Urgent Care Clinic/Center
-----------------------------------------------------
License Number | A39116
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207RP1001X
-----------------------------------------------------
Taxonomy Name | Pulmonary Disease Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------