Provider Demographics
NPI:1285780494
Name:SUNKIST MULTISPECIALTY MEDICAL CLINIC, INC
Entity type:Organization
Organization Name:SUNKIST MULTISPECIALTY MEDICAL CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICK
Authorized Official - Middle Name:JON
Authorized Official - Last Name:AUERBACH
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:626-960-8887
Mailing Address - Street 1:13909 AMAR RD STE B
Mailing Address - Street 2:
Mailing Address - City:LA PUENTE
Mailing Address - State:CA
Mailing Address - Zip Code:91746-1600
Mailing Address - Country:US
Mailing Address - Phone:626-960-8887
Mailing Address - Fax:626-338-0227
Practice Address - Street 1:13909 AMAR RD STE B
Practice Address - Street 2:
Practice Address - City:LA PUENTE
Practice Address - State:CA
Practice Address - Zip Code:91746-1600
Practice Address - Country:US
Practice Address - Phone:626-960-8887
Practice Address - Fax:626-338-0227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-28
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0087790Medicaid
CAG37465OtherMEDICARE RENDERING PHYS
CAS88588Medicare UPIN
CAWPA11646BMedicare ID - Type UnspecifiedRENDERING PROVIDER
CAG37465OtherMEDICARE RENDERING PHYS