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General NPI Number Information
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NPI Number | 1447396593
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Entity Type | Organization
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Legal Business Name | SAN MARCOS MEDICAL GROUP INC.
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Dates
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Enumeration Date | 01/29/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1574 W BASE LINE ST STE 107
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City | SAN BERNARDINO
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State | CA
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Zip | 92411-1736
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Country | US
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Telephone | 909-386-1880
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Fax | 909-386-1882
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Provider Business Mailing Address
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Address Line | 1574 W BASE LINE ST STE 107
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City | SAN BERNARDINO
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State | CA
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Zip | 92411-1736
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Country | US
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Telephone | 909-386-1880
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Fax | 909-386-1882
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Authorized Official
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Title or Position | ADMINISTRATER
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Name | AZER REZK
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Credential |
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Telephone | 909-376-7715
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number | LAB 69268F
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License Number State | CA
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