=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376614271
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | C.V. MEHTA MD MEDICAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/13/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 949 CALHOUN PLACE SUITE F
-----------------------------------------------------
City | HEMET
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92543-4403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-652-5000
-----------------------------------------------------
Fax | 951-765-6688
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 949 CALHOUN PL SUITE F
-----------------------------------------------------
City | HEMET
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92543-4403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-652-5000
-----------------------------------------------------
Fax | 951-765-6688
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MRS. DENI C MEHTA
-----------------------------------------------------
Credential | B.S.
-----------------------------------------------------
Telephone | 951-652-5000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 204C00000X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Neuromusculoskeletal Medicine) Physician
-----------------------------------------------------
License Number | A370440
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------