| Luther Mangoba, Md Inc. | |
|
9041 Magnolia Ave Suite 008 Riverside CA 92503-3900 | |
| (951) 687-0004 | |
| (951) 687-0080 |
| Full Name | Luther Mangoba, Md Inc. |
|---|---|
| Speciality | Family Medicine |
| Location | 9041 Magnolia Ave, Riverside, California |
| Authorized Official Name and Position | Luther Mangoba (PRESIDENT) |
| Authorized Official Contact | 9516870004 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Luther Mangoba, Md Inc. 9041 Magnolia Ave Suite 008 Riverside CA 92503-3900 Ph: (951) 687-0004 | Luther Mangoba, Md Inc. 9041 Magnolia Ave Suite 008 Riverside CA 92503-3900 Ph: (951) 687-0004 |
| NPI Number | 1558387209 |
|---|---|
| Provider Enumeration Date | 07/14/2006 |
| Last Update Date | 07/03/2014 |
| Medicare PECOS PAC ID | 9537292594 |
|---|---|
| Medicare Enrollment ID | O20100728000860 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1558387209 | NPI | - | NPPES |
| 05D1038270 | Other | CA | CLIA WAIVER CERTIFICATE |
| 00A775740 | Medicaid | CA |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | 05D1038270 (California) | Primary |
| Provider Name | Luther Mangoba |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1528041894 PECOS PAC ID: 2466403860 Enrollment ID: I20050202000963 |
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