| Grace Medical Spa | |
|
6900 Brockton Ave Ste 200 Riverside CA 92506-3818 | |
| (909) 664-4634 | |
| Not Available |
| Full Name | Grace Medical Spa |
|---|---|
| Speciality | Internal Medicine |
| Location | 6900 Brockton Ave Ste 200, Riverside, California |
| Authorized Official Name and Position | Phillip Alhir (COO) |
| Authorized Official Contact | 9096644634 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Grace Medical Spa 6900 Brockton Ave Ste 200 Riverside CA 92506-3818 Ph: (909) 664-4634 | Grace Medical Spa 6900 Brockton Ave Ste 200 Riverside CA 92506-3818 Ph: (909) 664-4634 |
| NPI Number | 1689357030 |
|---|---|
| Provider Enumeration Date | 08/11/2023 |
| Last Update Date | 12/08/2023 |
| Medicare PECOS PAC ID | 0446608087 |
|---|---|
| Medicare Enrollment ID | O20231121001188 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1689357030 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207R00000X | Internal Medicine | (* (Not Available)) | Primary |
| Provider Name | Anna Wilson |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1326073263 PECOS PAC ID: 3274537121 Enrollment ID: I20060906000611 |
| Provider Name | Melanchton A Mangoba |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1376605717 PECOS PAC ID: 8224113139 Enrollment ID: I20080317000164 |
| Provider Name | Mousa Matar |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1992116982 PECOS PAC ID: 2567737026 Enrollment ID: I20210907001912 |
| Provider Name | Branka Vidic |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1164112942 PECOS PAC ID: 0042666596 Enrollment ID: I20231019002883 |
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