Basic Information
| Provider Information | |||||||||
| NPI: | 1720120744 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHINO VALLEY FAMILY PHYSICIANS A MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13193 CENTRAL AVE. | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CHINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917103522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9094649675 | ||||||||
| FaxNumber: | 9095903898 | ||||||||
| Practice Location | |||||||||
| Address1: | 13193 CENTRAL AVE. | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CHINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917103522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9094649675 | ||||||||
| FaxNumber: | 9095903898 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2007 | ||||||||
| LastUpdateDate: | 09/15/2017 | ||||||||
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| AuthorizedOfficialLastName: | HERNANDEZ | ||||||||
| AuthorizedOfficialFirstName: | SALLY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9094649675 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1720120744 | 05 | CA | MEDICAID |