| Heacock Health Medical Group, Inc. | |
|
24060 Fir Ave Ste A Moreno Valley CA 92553-2895 | |
| (951) 242-3025 | |
| (951) 242-3902 |
| Full Name | Heacock Health Medical Group, Inc. |
|---|---|
| Speciality | Clinic/Center |
| Location | 24060 Fir Ave Ste A, Moreno Valley, California |
| Authorized Official Name and Position | Rafael Penunuri (MEDICAL DIRECTOR) |
| Authorized Official Contact | 9512423025 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Heacock Health Medical Group, Inc. 1860 Port Wheeler Pl Newport Beach CA 92660-6628 Ph: (949) 697-9954 | Heacock Health Medical Group, Inc. 24060 Fir Ave Ste A Moreno Valley CA 92553-2895 Ph: (951) 242-3025 |
| NPI Number | 1891251849 |
|---|---|
| Provider Enumeration Date | 02/14/2019 |
| Last Update Date | 02/14/2019 |
| Medicare PECOS PAC ID | 1456691450 |
|---|---|
| Medicare Enrollment ID | O20190328001215 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1891251849 | NPI | - | NPPES |
| 1760896336 | Medicaid | CA |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | (* (Not Available)) | Secondary |
| 261QU0200X | Clinic/center - Urgent Care | (* (Not Available)) | Primary |
| Provider Name | Rafael A Penunuri |
|---|---|
| Provider Type | Practitioner - General Practice |
| Provider Identifiers | NPI Number: 1831270362 PECOS PAC ID: 1759432396 Enrollment ID: I20090622000595 |
| Provider Name | Marcus Allan P Mercado |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1760896336 PECOS PAC ID: 0648532903 Enrollment ID: I20180326001596 |
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