Provider Demographics
NPI:1447495361
Name:ERNESTO T. SALAS, MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:ERNESTO T. SALAS, MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:G
Authorized Official - Last Name:SALAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-693-1159
Mailing Address - Street 1:27699 JEFFERSON AVE
Mailing Address - Street 2:SUITE 311
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92590-2661
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:27699 JEFFERSON AVE
Practice Address - Street 2:SUITE 311
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-2661
Practice Address - Country:US
Practice Address - Phone:951-693-1159
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-05
Last Update Date:2009-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA053434174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G09315Medicare UPIN
CA00A534340Medicare PIN