Provider Demographics
NPI:1538181573
Name:INLAND PHYSIATRY MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:INLAND PHYSIATRY MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:VANCE
Authorized Official - Middle Name:ZACHARY
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-506-5049
Mailing Address - Street 1:27475 YNEZ RD STE 342
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92591-4612
Mailing Address - Country:US
Mailing Address - Phone:951-506-5049
Mailing Address - Fax:951-296-1098
Practice Address - Street 1:900 E WASHINGTON ST STE 100
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-4120
Practice Address - Country:US
Practice Address - Phone:951-506-5049
Practice Address - Fax:951-296-1098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2013-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA61529208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty