Provider Demographics
NPI:1558736520
Name:MEDHERO SAN CLEMENTE, A PROFESSIONAL MEDICAL CORPORATION
Entity type:Organization
Organization Name:MEDHERO SAN CLEMENTE, A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:MORENO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-533-6656
Mailing Address - Street 1:905 CALLE AMANECER
Mailing Address - Street 2:SUITE 115
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-6274
Mailing Address - Country:US
Mailing Address - Phone:949-207-3603
Mailing Address - Fax:
Practice Address - Street 1:905 CALLE AMANECER
Practice Address - Street 2:SUITE 115
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-6274
Practice Address - Country:US
Practice Address - Phone:949-207-3603
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-02
Last Update Date:2025-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care