Moulton Family Medicine

Primary specialty

Non-Pharmacy Dispensing SiteTaxonomy code 332900000X

License

A47792 Issued in CA

Legal business name

MOULTON FAMILY MEDICINE

Practice address

22611 Lake Forest Dr
C-4
Lake Forest, CA 92630-1700

Phone

(949) 951-9399

NPI assigned

Feb 12, 2007

Organization subpart

Yes

Parent organization

MEDVANTX, INC.As reported in NPPES

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

Authorized official

Name

Kenny Heine

Title

Director of Operations

Phone

(858) 625-2990

Specialties & licenses 1

Addresses

Part of

Tri - State Medical Group Inc

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Adel Boutros, MD

  • Family Medicine Physician
  • Lake Forest, CA
  • NPI 1700952827
  NPD (past)

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

{
    "created_epoch": "1171238400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1350432000000",
    "number": "1164564712",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5626 OBERLIN DR",
            "address_2": "SUITE 110",
            "city": "SAN DIEGO",
            "state": "CA",
            "postal_code": "921211705"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "22611 LAKE FOREST DR",
            "address_2": "C-4",
            "city": "LAKE FOREST",
            "state": "CA",
            "postal_code": "926301700",
            "telephone_number": "949-951-9399"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MOULTON FAMILY MEDICINE",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "MEDVANTX, INC.",
        "enumeration_date": "2007-02-12",
        "last_updated": "2012-10-17",
        "status": "A",
        "authorized_official_last_name": "HEINE",
        "authorized_official_first_name": "KENNY",
        "authorized_official_title_or_position": "DIRECTOR OF OPERATIONS",
        "authorized_official_telephone_number": "858-625-2990"
    },
    "taxonomies": [
        {
            "code": "332900000X",
            "taxonomy_group": "",
            "desc": "Non-Pharmacy Dispensing Site",
            "state": "CA",
            "license": "A47792",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Shannon Morris
• Jon Dennis Morrison, OD
• Kathy Mortazavi, DDS
• Ricka Moshref
• Moulton Family Medical, Inc.
• Richard R Moy, DPM
• Mozhgan Molkara DDS,Inc.
• Muirlands Dental
• Kristi J Mukai
• Dezirae Munoz

• Non-Pharmacy Dispensing Site in Lake Forest, CA
• Providers in Lake Forest, CA by specialty
• Non-Pharmacy Dispensing Site in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 17, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.