=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215365754
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MORENO VALLEY URGENT CARE CLINIC, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2013
-----------------------------------------------------
Last Update Date | 10/18/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1744 UNIVERSITY AVE SUITE 100
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92507-5364
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-243-5586
-----------------------------------------------------
Fax | 951-243-5050
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24318 HEMLOCK AVE SUITE E1
-----------------------------------------------------
City | MORENO VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92557-7222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDNET / CEO
-----------------------------------------------------
Name | DR. JAMES ALVIN HARRISON
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 951-243-5050
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QU0200X
-----------------------------------------------------
Taxonomy Name | Urgent Care Clinic/Center
-----------------------------------------------------
License Number | A4349
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------