# MOULTON FAMILY MEDICAL, INC.

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1538190954
- **Authorized official:** NELLY BOUTROS (OWNER)
- **Authorized official phone:** (949) 951-9399

## Contact information

- **Practice address:** 22611 LAKE FOREST DR. \#C-4, LAKE FOREST, CA 92630
- **Practice address phone:** (949) 951-9399
- **Practice address fax:** (949) 951-9403
- **Mailing address:** PO BOX 8095, FOUNTAIN VALLEY, CA 92728-8095
- **Mailing address phone:** (949) 951-9399
- **Mailing address fax:** (949) 951-9399

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | — | NULL | Yes |
| 207Q00000X | Family Medicine Physician | — | — | Yes |

## Other

- **Enumeration date:** 07/05/2006
- **Last updated:** 08/22/2020