Basic Information
| Provider Information | |||||||||
| NPI: | 1811421670 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CITRUS VALLEY INDEPENDENT PHYSICIANS, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 210 W SAN BERNARDINO RD | ||||||||
| Address2: | |||||||||
| City: | COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917231515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6268588580 | ||||||||
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| Practice Location | |||||||||
| Address1: | 210 W SAN BERNARDINO RD | ||||||||
| Address2: | |||||||||
| City: | COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917231515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6268588580 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2017 | ||||||||
| LastUpdateDate: | 04/18/2017 | ||||||||
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| AuthorizedOfficialLastName: | TANGCHITNOB | ||||||||
| AuthorizedOfficialFirstName: | DUMRONG | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6268588577 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 302R00000X | Y | Managed Care Organizations | Health Maintenance Organization |
No ID Information.