Basic Information
| Provider Information | |||||||||
| NPI: | 1023659851 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OUR FAMILY MEDICAL GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 840 TOWNE CENTER DR | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917675900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093981550 | ||||||||
| FaxNumber: | 9093981488 | ||||||||
| Practice Location | |||||||||
| Address1: | 9190 HAVEN AVE STE 102 | ||||||||
| Address2: | |||||||||
| City: | RANCHO CUCAMONGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917305431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095278110 | ||||||||
| FaxNumber: | 9095816738 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2019 | ||||||||
| LastUpdateDate: | 10/08/2020 | ||||||||
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| AuthorizedOfficialLastName: | SALSBERRY | ||||||||
| AuthorizedOfficialFirstName: | SYLVIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9093981550 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207RG0300X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
No ID Information.