Provider Demographics
NPI:1063279651
Name:SOUTHERN CALIFORNIA PERMANENTE MEDICAL GROUP
Entity type:Organization
Organization Name:SOUTHERN CALIFORNIA PERMANENTE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEPARTMENT ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MADONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLBROOK-LOWE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-233-0023
Mailing Address - Street 1:3951 VAN BUREN BLVD
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-3620
Mailing Address - Country:US
Mailing Address - Phone:866-883-0119
Mailing Address - Fax:
Practice Address - Street 1:3951 VAN BUREN BLVD
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-3620
Practice Address - Country:US
Practice Address - Phone:866-862-4295
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-01
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty