1962464529 NPI number — CHAPARRAL MEDICAL GROUP INC

Table of content: (NPI 1962464529)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962464529 NPI number — CHAPARRAL MEDICAL GROUP INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHAPARRAL 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:
1962464529
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/04/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
840 TOWNE CENTER DR
Provider Second Line Business Mailing Address:
ADMINISTRATIVE RESOURCES
Provider Business Mailing Address City Name:
POMONA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91767-5900
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-398-1550
Provider Business Mailing Address Fax Number:
909-398-1573

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
430 WEST BASELINE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLAREMONT
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91711-1696
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-621-3916
Provider Business Practice Location Address Fax Number:
909-625-0903
Provider Enumeration Date:
04/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WALKER
Authorized Official First Name:
ADRIENNE
Authorized Official Middle Name:
M
Authorized Official Title or Position:
CONTRACTS ADMINISTRATOR
Authorized Official Telephone Number:
909-398-1550

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: GR0052953 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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