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General NPI Number Information
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NPI Number | 1598027112
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Entity Type | Organization
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Legal Business Name | GREEN RIVER MEDICAL & AESTHETIC CENTRE INC.
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Dates
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Enumeration Date | 06/11/2012
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Last Update Date | 08/22/2014
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Provider Practice Location Address
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Address Line | 2791 GREEN RIVER #103
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City | CORONA
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State | CA
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Zip | 92882-7426
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Country | US
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Telephone | 951-735-5570
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Fax | 951-735-5572
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Provider Business Mailing Address
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Address Line | PO BOX 18706
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City | ANAHEIM
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State | CA
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Zip | 92817-8706
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Country | US
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Telephone | 951-735-5570
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Fax | 951-735-5572
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Authorized Official
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Title or Position | C.O.O
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Name | DR. RICHARD B MANTELL
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Credential | M.D.
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Telephone | 951-735-5570
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA0005X
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Taxonomy Name | Ambulatory Family Planning Facility
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License Number | NPF20032
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License Number State | CA
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