Provider Demographics
NPI:1649467093
Name:MENIFEE VALLEY MEDICAL ASSOCIATION
Entity type:Organization
Organization Name:MENIFEE VALLEY MEDICAL ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:HAYNES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-301-9188
Mailing Address - Street 1:29798 HAUN RD STE 203
Mailing Address - Street 2:
Mailing Address - City:SUN CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92586-6541
Mailing Address - Country:US
Mailing Address - Phone:951-301-9188
Mailing Address - Fax:951-672-6132
Practice Address - Street 1:29798 HAUN RD STE 203
Practice Address - Street 2:
Practice Address - City:SUN CITY
Practice Address - State:CA
Practice Address - Zip Code:92586-6541
Practice Address - Country:US
Practice Address - Phone:951-301-9188
Practice Address - Fax:951-672-6132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-01
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG61994251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ15743ZMedicare PIN