Basic Information
Provider Information | |||||||||
NPI: | 1629383740 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CHAPARRAL MEDICAL GROUP, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 840 TOWNE CENTER DR | ||||||||
Address2: |   | ||||||||
City: | POMONA | ||||||||
State: | CA | ||||||||
PostalCode: | 917675900 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9093981550 | ||||||||
FaxNumber: | 9093981573 | ||||||||
Practice Location | |||||||||
Address1: | 1818 N ORANGE GROVE AVE | ||||||||
Address2: | SUITE 302 | ||||||||
City: | POMONA | ||||||||
State: | CA | ||||||||
PostalCode: | 917673028 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9096296200 | ||||||||
FaxNumber: | 9098652700 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/12/2010 | ||||||||
LastUpdateDate: | 06/14/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WALKER | ||||||||
AuthorizedOfficialFirstName: | ADRIENNE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CONTRACTS MANAGER | ||||||||
AuthorizedOfficialTelephone: | 9093981550 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
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AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | A85637 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |   |
No ID Information.