OrganizationActive
Moulton Family Medicine
NPI 1164564712 · Non-Pharmacy Dispensing Site · Lake Forest, CA
Provider details
- NPI number
- 1164564712
- Entity type
- Organization
- Primary specialty
- Non-Pharmacy Dispensing SiteSuppliers
- Parent organization
- Medvantx, Inc.
- Organization subpart
- Yes
- Authorized official
- Kenny Heine, Director of Operations(858) 625-2990
- License
- A47792 (CA)
Specialties & taxonomies
Suppliers
Profile Score
Detailed profile(90/100 index)
A profile completeness & documented-activity index — NOT a quality, outcomes, or patient-satisfaction rating.
- Registry tenure38% of score
19 yrs in NPPES registry
- Profile completeness38% of score
100% of core fields populated
- Practice footprint23% of score
1 documented practice location
Signals a provider has no public data for (e.g. Medicare claims) are left out of the score entirely — never counted as zero — so providers without that data are not penalized. See the full formula and weights in our methodology.
Practice location
22611 Lake Forest Dr
C-4
Lake Forest, CA 92630-1700
Phone: (949) 951-9399
Street-level locationGet directions
Mailing address
5626 Oberlin Dr
San Diego, CA 92121-1705
Registry dates
- Enumerated
- 2007-02-12
- Last updated
- 2012-10-17
Source: CMS NPPES Data Dissemination (June 2026). NPI Central is not affiliated with CMS. Data is provided as-is from the public registry.