Provider Demographics
NPI:1316135569
Name:FIDELIS HEALTH GROUP LLC
Entity type:Organization
Organization Name:FIDELIS HEALTH GROUP LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WAGNER
Authorized Official - Middle Name:A
Authorized Official - Last Name:LEMUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-815-0800
Mailing Address - Street 1:1002 S BALDWIN AVE
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91007-7234
Mailing Address - Country:US
Mailing Address - Phone:626-447-2138
Mailing Address - Fax:626-447-6433
Practice Address - Street 1:1002 S BALDWIN AVE
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91007-7234
Practice Address - Country:US
Practice Address - Phone:626-447-2138
Practice Address - Fax:626-447-6433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-11
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
CAPHY525103336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1316135569Medicaid
2149274OtherPK
CB231925Medicare PIN