Provider Demographics
NPI:1679749501
Name:MORENO VALLEY FAMILY HEALTH CENTER
Entity type:Organization
Organization Name:MORENO VALLEY FAMILY HEALTH CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-571-2300
Mailing Address - Street 1:22675 ALESSANDRO BLVD
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-8551
Mailing Address - Country:US
Mailing Address - Phone:951-571-2300
Mailing Address - Fax:951-571-2330
Practice Address - Street 1:22675 ALESSANDRO BLVD
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-8551
Practice Address - Country:US
Practice Address - Phone:951-571-2350
Practice Address - Fax:951-571-2370
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY HEALTH SYSTEMS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-30
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40093122300000X
CA27343122300000X
CA468941223G0001X
CA479871223P0221X
CAOPT5169TPA152W00000X
CAA99343207Q00000X
CA550000802207Q00000X
CA6440207Q00000X
CAA50693207Q00000X
CA11428207Q00000X
CA10648207V00000X
261QF0400X
CA436046363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANPI 1679749501Medicaid
CAEAP70324FMedicare PIN
CA051192Medicare PIN
CANPI 1679749501Medicaid