=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386132041
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REMEDIAL MEDICAL GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/27/2018
-----------------------------------------------------
Last Update Date | 05/08/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12730 HEACOCK ST STE 4A
-----------------------------------------------------
City | MORENO VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92553-3040
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-243-8517
-----------------------------------------------------
Fax | 951-243-8617
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12730 HEACOCK ST STE 4A
-----------------------------------------------------
City | MORENO VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92553-3040
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-243-8517
-----------------------------------------------------
Fax | 951-243-8617
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | RAFAEL ARTURO PENUNURI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 951-243-8517
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------