Basic Information
| Provider Information | |||||||||
| NPI: | 1811222078 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MT. VERNON MEDICAL CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1023 S MOUNT VERNON AVE | ||||||||
| Address2: | |||||||||
| City: | COLTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923244202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9094228015 | ||||||||
| FaxNumber: | 9094220625 | ||||||||
| Practice Location | |||||||||
| Address1: | 1023 S MOUNT VERNON AVE | ||||||||
| Address2: | |||||||||
| City: | COLTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923244202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9094228015 | ||||||||
| FaxNumber: | 9094220625 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2009 | ||||||||
| LastUpdateDate: | 10/06/2009 | ||||||||
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| AuthorizedOfficialLastName: | SHAMLOO | ||||||||
| AuthorizedOfficialFirstName: | J | ||||||||
| AuthorizedOfficialMiddleName: | JAMES | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9094228015 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 49937 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.