MEDICARE: ORTHOPAEDIC MEDICAL GROUP OF RIVERSIDE, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	PSY11922	CA
2	261QP2000X	Physical Therapy Clinic/Center	PT29088	CA

General Provider Information

NPI Number	:	1124050620
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ORTHOPAEDIC MEDICAL GROUP OF RIVERSIDE, INC.

Provider Business Mailing Address
First Line	:	6850 BROCKTON AVE
Second Line	:	SUITE 212
City	:	RIVERSIDE
State	:	CA
Zip	:	92506-3808
Country	:	US
Telephone Number	:	951-774-4611
Fax Number	:	951-276-3597

Provider Business Practice Location Address
First Line	:	6860 BROCKTON AVE
Second Line	:	SUITE 7
City	:	RIVERSIDE
State	:	CA
Zip	:	92506-3816
Country	:	US
Telephone Number	:	951-369-0860
Fax Number	:	951-774-4623

Authorized Official
Title or Position	:	CEO
Name	:	MR. JUAN D. GUAJARDO
Credential	:
Telephone Number	:	951-774-4611

Provider Enumeration Date	:	07/07/2006
Last Update Date	:	06/20/2008

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