=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689036121
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRUE DOC MEDICAL GROUP INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2016
-----------------------------------------------------
Last Update Date | 03/23/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 770 MAGNOLIA AVE STE 2C
-----------------------------------------------------
City | CORONA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92879-3122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-737-0110
-----------------------------------------------------
Fax | 951-737-5944
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2469 POMONA RD STE 101
-----------------------------------------------------
City | CORONA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92880-6928
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-285-7881
-----------------------------------------------------
Fax | 951-737-1167
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MOWBRAY P HAGAN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 951-734-6110
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 544451
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------