1053096040 NPI number — CHINO STONE & SURGERY CENTER

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053096040 NPI number — CHINO STONE & SURGERY CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHINO STONE & SURGERY CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053096040
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/26/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12611 9TH STREET
Provider Second Line Business Mailing Address:
SUITE D
Provider Business Mailing Address City Name:
CHINO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91710-3528
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-480-4968
Provider Business Mailing Address Fax Number:
909-206-0628

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12611 9TH STREET
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
CHINO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91710-3528
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-902-0009
Provider Business Practice Location Address Fax Number:
909-206-0628
Provider Enumeration Date:
06/19/2023

Additional Information

Authorized Official

Authorized Official Last Name:
SONG
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
G
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
909-902-0009

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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