# MOULTON FAMILY MEDICINE

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- **Entity:** Organization
- **Status:** Active
- **Parent organization:** MEDVANTX, INC.
- **Organization subpart:** Yes

## Provider details

- **NPI number:** 1164564712
- **Legal business name:** MEDVANTX, INC.
- **Authorized official:** KENNY HEINE (DIRECTOR OF OPERATIONS)
- **Authorized official phone:** (858) 625-2990

## Contact information

- **Practice address:** 22611 LAKE FOREST DR, C-4, LAKE FOREST, CA 92630-1700
- **Practice address phone:** (949) 951-9399
- **Mailing address:** 5626 OBERLIN DR, SUITE 110, SAN DIEGO, CA 92121-1705

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 332900000X | Non-Pharmacy Dispensing Site | A47792 | CA | Yes |

## Other

- **Enumeration date:** 02/12/2007
- **Last updated:** 10/17/2012