Basic Information
| Provider Information | |||||||||
| NPI: | 1376506956 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHAPARRAL MEDICAL GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 840 TOWNE CENTER DR | ||||||||
| Address2: | ADMINISTRATIVE RESOURCES | ||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917675900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093981550 | ||||||||
| FaxNumber: | 9093981573 | ||||||||
| Practice Location | |||||||||
| Address1: | 138 HARVARD AVE | ||||||||
| Address2: | CHAPARRAL MEDICAL GROUP | ||||||||
| City: | CLAREMONT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917114716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096244503 | ||||||||
| FaxNumber: | 9096246364 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2006 | ||||||||
| LastUpdateDate: | 04/18/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/11/2022 | ||||||||
| NPIReactivationDate: | 04/18/2022 | ||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WALKER | ||||||||
| AuthorizedOfficialFirstName: | ADRIENNE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CONTRACTS ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9093981550 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | 04/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 207RE0101X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | GR0052951 | 05 | CA | MEDICAID |