Provider Demographics
NPI:1063718930
Name:LAS PALMAS MEDICAL GROUP
Entity type:Organization
Organization Name:LAS PALMAS MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:
Authorized Official - Last Name:MENA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-480-4747
Mailing Address - Street 1:1540 E VALLEY PKWY
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92027-2316
Mailing Address - Country:US
Mailing Address - Phone:760-621-4902
Mailing Address - Fax:760-400-0012
Practice Address - Street 1:1540 E VALLEY PKWY
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92027-2316
Practice Address - Country:US
Practice Address - Phone:760-621-4902
Practice Address - Fax:760-400-0012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-09
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG57022208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1164503652Medicaid
CA1770663551Medicaid
CA1164503652Medicaid
CAW17224Medicare PIN