Basic Information
Provider Information | |||||||||
NPI: | 1053350884 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CHINO MEDICAL GROUP, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5475 WALNUT AVE | ||||||||
Address2: |   | ||||||||
City: | CHINO | ||||||||
State: | CA | ||||||||
PostalCode: | 917102609 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9095916446 | ||||||||
FaxNumber: | 9095911309 | ||||||||
Practice Location | |||||||||
Address1: | 5475 WALNUT AVE | ||||||||
Address2: |   | ||||||||
City: | CHINO | ||||||||
State: | CA | ||||||||
PostalCode: | 917102609 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9095916446 | ||||||||
FaxNumber: | 9095911309 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/06/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LIRA | ||||||||
AuthorizedOfficialFirstName: | JOSE ALEX | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 9095916446 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X |   |   | X |   | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical | 261QE0800X |   |   | X |   | Ambulatory Health Care Facilities | Clinic/Center | Endoscopy |
No ID Information.