MEDICARE: MISSION GROVE MEDICAL CORPORATION

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	363L00000X	Nurse Practitioner
2	261QU0200X	Urgent Care Clinic/Center	A39116	CA
3	207RP1001X	Pulmonary Disease Physician

General Provider Information

NPI Number	:	1205224417
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MISSION GROVE MEDICAL CORPORATION

Provider Business Mailing Address
First Line	:	191 E ALESSANDRO BLVD # 9A
Second Line	:
City	:	RIVERSIDE
State	:	CA
Zip	:	92508-5095
Country	:	US
Telephone Number	:	951-780-3300
Fax Number	:

Provider Business Practice Location Address
First Line	:	191 E. ALESSANDRO BLVD #9A
Second Line	:
City	:	RIVERSIDE
State	:	CA
Zip	:	92508-5095
Country	:	US
Telephone Number	:	951-780-3300
Fax Number	:

Authorized Official
Title or Position	:	AO
Name	:	JEAN LACOMBE
Credential	:
Telephone Number	:	951-780-3300

Provider Enumeration Date	:	12/23/2014
Last Update Date	:	03/20/2025

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Directions to “MISSION GROVE MEDICAL CORPORATION ” Practice Location

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