=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760919492
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STRATEGIC MEDICAL PARTNERS A PROFESSIONAL CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2017
-----------------------------------------------------
Last Update Date | 05/12/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10683 MAGNOLIA AVE SUITE B
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92505-1800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-785-0381
-----------------------------------------------------
Fax | 951-639-6024
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10683 MAGNOLIA AVE SUITE B
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92505-1800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-785-0381
-----------------------------------------------------
Fax | 951-639-6024
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL DIRECTOR
-----------------------------------------------------
Name | MICHELE MARTINEZ
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 951-785-0381
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 405300000X
-----------------------------------------------------
Taxonomy Name | Prevention Professional
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------