Basic Information
| Provider Information | |||||||||
| NPI: | 1932383148 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INLAND HEALTHCARE GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1980 ORANGE TREE LN | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | REDLANDS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923744534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093357171 | ||||||||
| FaxNumber: | 9093357140 | ||||||||
| Practice Location | |||||||||
| Address1: | 17171 FOOTHILL BLVD. | ||||||||
| Address2: | SUITE E | ||||||||
| City: | FONTANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093565757 | ||||||||
| FaxNumber: | 9093565608 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/24/2007 | ||||||||
| LastUpdateDate: | 12/24/2007 | ||||||||
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| AuthorizedOfficialLastName: | PERKO | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9093357171 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | GR0062061 | 05 | CA | MEDICAID |