Medi-Cal Suspended and Ineligible Provider List: October Update

ADDITIONS:

Osteopath (susp A)

Nguyen, Tuan Hai 20A7361 Suspended

Physician/Surgeon 00AX73610 indefinitely effective

16119 Mount Kenya Ct. 1982771697 8/20/2013

Fountain Valley, CA

and

11180 Warner Ave.

Ste. #153

Fountain Valley, CA

Physician (susp A)

Emerson, Derek Kim A109882 Suspended

1053 Sapphire St. indefinitely effective

Unit #5 4/19/2013

San Diego, CA

Tincopa-Minan, Luis F. A31264 Suspended

7507 Seville Ave. 00A312640 indefinitely effective

Huntington Park, CA 00A312641 6/10/2013

and 1255322707

8420 Lindante Dr.

Whittier, CA

and

6301 Greenleaf Ave.

Whittier, CA

Counselor (susp C)

Alverson, Cynthia Louise Suspended

1014 Flint Ave. indefinitely effective

Wilmington, CA 8/20/2013

Psychologist (susp C)

De Lestang, Katherine PSY 11610 Suspended

3930 Laurel Canyon Blvd. indefinitely effective

Ste. #211 3/28/2013

Studio City, CA

Pharmaceutical Technician (susp E)

Leyva-Gonzalez, VB60090180 Suspended

Francisco J. -WA indefinitely effective

2590 Meadow Brook Ln. TCH38071-CA 8/20/2013

Tracy, CA

Dental Assistant (susp G)

Collins, Katie Diana 71562 Suspended

4425 Mission Ave. indefinitely effective

Unit E203 1/25/2013

Oceanside, CA

Martinez, Delina Renee Suspended

115 Duncan St. indefinitely effective

Stockton, CA 8/20/2013

Dentist (susp G)

Garcelon, Stephen 25799 Suspended

William. B25799 indefinitely effective

530 Arlene Dr. D25799 8/20/2013

Vacaville, CA

Dentist (susp G) …. (continued)

Rucker, Raymond. B27831 Suspended

James Jr. D27831 indefinitely effective

34 6th St. DDS27831 8/20/2013

Apt. #507

San Francisco, CA

Chiropractor (susp J)

Chung, Christian DC27406 Suspended

Eunsung indefinitely effective

Inmate Reg. #41454-086 8/20/2013

FCI Mendota

P.O. Box 9

Mendota, CA

Cleveland, Christopher DC27977 Suspended

Manuel indefinitely effective

945 S. Kern Ave. 9/30/2013

Los Angeles, CA

Lee, Ku II 1508193392 Suspended

Inmate Reg. #61152-112 indefinitely effective

CI Taft 8/20/2013

P.O. Box 7001

Taft, CA

Parks, Erich R. DC14716 Suspended

3720 Grass Valley Hwy. DC0141760 indefinitely effective

Auburn, CA 2/23/2013

and

11879 Kemper Rd.

Ste. #3

Auburn, CA

Certified Nurse Assistant (susp R)

Urbina, Susana A. 511203 Suspended

aka: Susana A. Matute indefinitely effective

3371 Baltic Ave. 8/20/2013

Long Beach, CA

Licensed Vocational Nurse (susp R)

Cody, Joe Daniel Jr. 166026 Suspended

Victorville Correctional indefinitely effective

Center 9/30/2013

Medium II

13777 Air Expressway Blvd.

Victorville, CA

Registered Nurse (susp R)

Alfonso, Victoria Marie 498033 Suspended

14835 Ox Cart Ln. indefinitely effective

Draper, UT 3/28/2013

Eubanks, Patrick Allan 770256 Suspended

133 10th St. indefinitely effective

Unit #2 3/29/2013

Seal Beach, CA

Hughes, Gwen Diane 260423 Suspended

aka: Gwen Geoghegan indefinitely effective

aka: Gwen Newell 9/30/2013

aka: Gwen D. Varga

aka: Gwen D. Hunn

aka: Gwen D. Ruskin

6851 Plymouth Rd.

Stockton, CA

Janiszewski, Frank 620992-CA Suspended

8410 Shining Waters Ln. 569164-TX indefinitely effective

Arlington, TX 4/11/2013

Registered Nurse (susp R) …. (continued)

Kemmer, Michelle Lynn 754744 Suspended

106 5th St. indefinitely effective

Brookville, PA 3/18/2013

Kim, Hwa Ja Suspended

aka: Helen Kim indefinitely effective

Inmate Reg. #62915-112 8/20/2013

FCI Victorville

Medium II

PO Box 3850

Adelanto, CA

Respiratory Care Practitioner (susp S)

Grosman, Vadim 28013 Suspended

1339 N. Sycamore Dr. indefinitely effective

Apt. #202 3/11/2013

Los Angeles, CA

Vera, Raymond 4369 Suspended

1339 N. Sycamore Dr. indefinitely effective

Apt. #202 3/23/2013

Los Angeles, CA

Business Manager (susp T)

Blkhoian, Hasmik Jasmine Suspended

aka: Asmik Blkhoian indefinitely effective

Inmate Reg. #56924-112 8/20/2013

FCI Victorville

Medium II

PO Box 3850

Adelanto, CA

Villanueva, Carlos 1629298831 Suspended

New Beginnings indefinitely effective

Recovery Treatment 8/20/2013

Center

9050 Carron Dr.

Apt. #100

Pico Rivera, CA

Business Owner (susp T)

Davtyan, Anush Suspended

Inmate Reg. #61449-112 indefinitely effective

MDC Los Angeles 8/20/2013

P.O. Box 1500

Los Angeles, CA

Corporation (susp T)

Dental Hygiene Center Suspended

Mobile Service Inc. indefinitely effective

7352 Foothill Blvd. 9/24/2013

Unit #103

Tujunga, CA

Employee (susp T)

Caffrey, Teresa Suspended

6376 Italia Ave. indefinitely effective

Las Vegas, NV 9/24/2013

Kulakova, Olena E. Suspended

aka: Olena Kulakova indefinitely effective

Inmate Reg. #87581-008 8/20/2013

3620 West Bethany Home Rd.

Phoenix, AZ

Rozenberg, Ella Suspended

2309 Apollo Dr. indefinitely effective

Los Angeles, CA 8/20/2013

Employee (susp T) …. (continued)

Scroggins, Alicia Suspended

148 E. Imperial Hwy. indefinitely effective

Los Angeles, CA 9/3/2013

Marketer (susp T)

Seville, Alexander Suspended

Biller indefinitely effective

19301 Superior St. 8/20/2013

Northridge, CA

Medical Assistant (susp T)

Reyes, Raymond Suspended

Inmate Reg. #19206-097 indefinitely effective

c/o FCI Terminal Island 8/20/2013

Federal Correctional

Institution

P.O. Box 3007

San Pedro, CA

Operator (susp T)

Satamyan, Andranik Suspended

aka: Andy Adranik indefinitely effective

Satamyan 8/20/2013

2219 Lenore Dr.

Glendale, CA

Sales Representative (susp T)

Valentine, Thomas C. Suspended

General Manager for Sanofi indefinitely effective

44 Gardenpath 8/20/2013

Irvine, CA

In-Home Support Services Provider (susp U)

Alverson, Cynthia Louise Suspended

1014 Flint Ave. indefinitely effective

Wilmington, CA 8/20/2013

Barker, Vincent Lamar Suspended

659 W. 59th Pl. indefinitely effective

Los Angeles, CA 9/24/2013

Brown, Katrina Patrice Suspended

1823 W. 87th St. indefinitely effective

Apt. #11 9/30/2013

Los Angeles, CA

Byrd, Thomas Ray Suspended

CDC #AN8885 indefinitely effective

c/o Wasco State Prison 8/20/2013

Facility D

701 Scofield Ave.

P.O. Box 4400

Wasco, CA

Cardenas, Maria Del Carmen Suspended

aka: Carmen Cardenas indefinitely effective

3689 N. Fruit Ave. 8/20/2013

Unit B

Fresno, CA

Gross, Sandra L. Suspended

1823 W. 87th St. indefinitely effective

Apt. #11 9/30/2013

Los Angeles, CA

In-Home Support Services Provider (susp U) …. (continued)

Jennings, Paul Russell Suspended

524 E. Hazel St. indefinitely effective

Unit #2 9/9/2013

Inglewood, CA

Sua, Christy Marie Suspended

212 E. Adell St. indefinitely effective

Madera, CA 8/20/2013

Ward, Jonathan Kaofas Suspended

379 Willits St. indefinitely effective

Daly City, CA 8/20/2013

REINSTATEMENTS:

Pharmacy (susp E)

Kim, Martin Choongsub PHY32469 9/4/2013 (removed from pg. 4)

dba: Martin Pharmacy

1303 Beech Ave.

Torrance, CA

and

801 S. Vermont Ave.

Unit #104

Los Angeles, CA

and

3400 Lomita Blvd.

Ste. #102

Torrance, CA

Respiratory Care Practitioner (susp S)

Carter, Michael Anson 10886 9/3/2013 (removed from pg. 4)

10720 Farralone Ave.

Chatsworth, CA

CORRECTIONS:

(Corrections to existing list are bolded)

Physician Assistant (susp A)

Hunter, Marysa S. PA50917 Suspended (corrected on pg. 109)

35150 East Creek Rd. indefinitely effective

Victorville, CA 11/9/2012

Chiropractor (susp J)

El-Shimey, Mohamed 31876 Suspended (corrected on pg. 9)

aka: Mohamed El Shamey indefinitely effective

aka: Mohamed El Sayed El 11/9/2012

Shamey

15564 Hesperian Blvd.

San Lorenzo, CA

and

1929 Carlotta Dr.

Apt. #2

Concord, CA