NPIMap

Organization Active NPI

Canyon Springs Medical Group, Inc.

  • Family Medicine Physician
  • Moreno Valley, CA
National Provider Identifier
1073669404
Registry record updated Apr 23, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
CANYON SPRINGS MEDICAL GROUP, INC.
Practice address
26520 Cactus Ave RM B2018
Moreno Valley, CA 92555-3927
Phone
(951) 486-5610
Fax
(951) 486-5620
NPI assigned
Jan 26, 2007
Last updated
Apr 23, 2018By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 23, 2018

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Faheem M. Jukaku, M.D.NPI 1518072230
Title
President
Phone
(951) 486-5610

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207Q00000X Primary

Addresses

Primary practice location

26520 Cactus Ave RM B2018
Moreno Valley, CA 92555-3927

Mailing address

26520 Cactus Ave
Moreno Valley, CA 92555-3927
Phone (951) 486-5610

Other practice location 1

26520 Cactus Ave Rm B2018
Moreno Valley, CA 92555-3927
Phone (951) 486-5610

Other identifiers 1

IdentifierTypeStateIssuer
GR0088740MedicaidCA

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20050408000993 CA Part B Supplier - Clinic/Group Practice 0446297634 Receives reassigned benefits from 25 practitioners
Practice locations: Moreno Valley, CA

National Provider Directory

National Provider Directory

Locations

26520 Cactus Ave
Rm B2018
Moreno Valley, CA 92555
Phone (909) 486-5610

Practitioners & affiliated clinicians

Practitioners 31

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 31

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1169769600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1524441600000",
    "number": "1073669404",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "26520 CACTUS AVE",
            "city": "MORENO VALLEY",
            "state": "CA",
            "postal_code": "925553927",
            "telephone_number": "951-486-5610",
            "fax_number": "951-486-5620"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "26520 CACTUS AVE RM B2018",
            "city": "MORENO VALLEY",
            "state": "CA",
            "postal_code": "925553927",
            "telephone_number": "951-486-5610",
            "fax_number": "951-486-5620"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "26520 Cactus Ave Rm B2018",
            "address_purpose": "LOCATION",
            "city": "Moreno Valley",
            "state": "CA",
            "postal_code": "925553927",
            "country_code": "US",
            "telephone_number": "951-486-5610",
            "fax_number": "951-486-5620",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "CANYON SPRINGS MEDICAL GROUP, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-01-26",
        "last_updated": "2018-04-23",
        "status": "A",
        "authorized_official_last_name": "JUKAKU",
        "authorized_official_first_name": "FAHEEM",
        "authorized_official_middle_name": "M.",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "951-486-5610",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "GR0088740",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Moreno Valley, CA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 23, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.