=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467635276
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CITRUS VALLEY URGENT CARE MEDICAL GROUP, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/14/2007
-----------------------------------------------------
Last Update Date | 12/14/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 854 MAGNOLIA AVE STE. 101
-----------------------------------------------------
City | CORONA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92879-3109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-737-0910
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 854 MAGNOLIA AVE STE. 101
-----------------------------------------------------
City | CORONA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92879-3109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-737-0910
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MR. ROBERT GUY NELSON JR.
-----------------------------------------------------
Credential | MBA
-----------------------------------------------------
Telephone | 951-737-0910
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | C2181465
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------