Provider Demographics
NPI:1124172796
Name:MURRIETA VALLEY FAMILY MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:MURRIETA VALLEY FAMILY MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:G
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-698-7550
Mailing Address - Street 1:24910 LAS BRISAS RD STE 121
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-4035
Mailing Address - Country:US
Mailing Address - Phone:951-698-7550
Mailing Address - Fax:951-698-1521
Practice Address - Street 1:24910 LAS BRISAS RD STE 121
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-4035
Practice Address - Country:US
Practice Address - Phone:951-698-7550
Practice Address - Fax:951-698-1521
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG453820174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G453820Medicare PIN