Organization
BEAVER MEDICAL GROUP LP
Active
Parent organization
MEDVANTX, INC.
Other names
Beaver Medical Group - Cooley Ranch
Organization subpart
Yes
Provider details
NPI number
Legal business name
MEDVANTX, INC.
Authorized official
KENNY HEINE (VP OF OPERATIONS)
(858) 625-2990
Entity
Organization
Contact information
Practice address
1300 E COOLEY DR, COLTON, CA 92324-3905
(909) 270-4179
Mailing address
5626 OBERLIN DR, SUITE 110, SAN DIEGO, CA 92121-1705
Taxonomy
Speciality
Code
Description
License number
State
332900000X
Non-Pharmacy Dispensing Site
Primary
G58149
CA
Other
Enumeration date
02/04/2008
Last updated
04/25/2013
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