1164063897 NPI number — INLAND EMPIRE MEDICAL GROUP INC.

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 1164063897 NPI number — INLAND EMPIRE MEDICAL GROUP INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INLAND EMPIRE MEDICAL GROUP INC.
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:
1164063897
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/03/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1550 E WASHINGTON ST # 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLTON
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92324-4624
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-418-0850
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1550 E WASHINGTON ST # 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLTON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92324-4624
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-418-0850
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/03/2019

Additional Information

Authorized Official

Authorized Official Last Name:
GILLIARD
Authorized Official First Name:
DERON
Authorized Official Middle Name:
A
Authorized Official Title or Position:
MANAGING PARTNER
Authorized Official Telephone Number:
909-581-5447

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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