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General NPI Number Information
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NPI Number | 1710029368
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Entity Type | Organization
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Legal Business Name | MEMORIALCARE MEDICAL GROUP, INC.
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Dates
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Enumeration Date | 02/12/2007
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Last Update Date | 04/03/2013
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Provider Practice Location Address
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Address Line | 15 MAREBLU SUITE 100
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City | ALISO VIEJO
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State | CA
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Zip | 92656-3015
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Country | US
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Telephone | 949-448-0656
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Fax |
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Provider Business Mailing Address
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Address Line | 5626 OBERLIN DR SUITE 110
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City | SAN DIEGO
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State | CA
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Zip | 92121-1705
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Country | US
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Telephone | 858-625-2990
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Fax |
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Authorized Official
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Title or Position | VP OF OPERATIONS
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Name | KENNY HEINE
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Credential |
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Telephone | 858-625-2990
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332900000X
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Taxonomy Name | Non-Pharmacy Dispensing Site
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License Number | A43924
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License Number State | CA
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