=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346556107
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MI CARE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2010
-----------------------------------------------------
Last Update Date | 08/31/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3975 JACKSON ST #206
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92503-3901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-588-7685
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5198 ARLINGTON AVE #610
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92504-2603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-588-7658
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MICHAEL S PROVENGHI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 951-588-7658
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | A86795
-----------------------------------------------------
License Number State |
-----------------------------------------------------