=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639129372
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAN MARCOS MEDICAL GROUP INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2006
-----------------------------------------------------
Last Update Date | 04/29/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7965 SIERRA AVE
-----------------------------------------------------
City | FONTANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92336-3329
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-356-4459
-----------------------------------------------------
Fax | 909-355-4261
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7965 SIERRA AVE
-----------------------------------------------------
City | FONTANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92336-3329
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-356-4459
-----------------------------------------------------
Fax | 909-355-4261
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MD/PRESIDENT
-----------------------------------------------------
Name | NATT BALBIR
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 951-751-5470
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | GR0086722
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------