Provider Demographics
NPI:1124519855
Name:LIZARRAGA MEDICAL CLINIC INC.
Entity type:Organization
Organization Name:LIZARRAGA MEDICAL CLINIC INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:FERNANDO
Authorized Official - Last Name:LIZARRAGA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-405-6299
Mailing Address - Street 1:2090 S EUCLID ST STE 104
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92802-3141
Mailing Address - Country:US
Mailing Address - Phone:714-539-2200
Mailing Address - Fax:714-539-2277
Practice Address - Street 1:895 W VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-2001
Practice Address - Country:US
Practice Address - Phone:909-824-3389
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-30
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1417126764OtherA49181