Provider Demographics
NPI:1902959075
Name:CLINICA GUADALUPANA DE ONTARIO MED GRP
Entity Type:Organization
Organization Name:CLINICA GUADALUPANA DE ONTARIO MED GRP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:FRANCISCO
Authorized Official - Middle Name:A
Authorized Official - Last Name:JIMENEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-391-3616
Mailing Address - Street 1:308 N 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-8325
Mailing Address - Country:US
Mailing Address - Phone:909-920-9193
Mailing Address - Fax:909-920-6019
Practice Address - Street 1:308 N 2ND AVE
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-8325
Practice Address - Country:US
Practice Address - Phone:909-920-9193
Practice Address - Fax:909-920-6019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA40305207Q00000X
CAA40070207Q00000X
CAG15628208000000X
CAE3702213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE50611Medicare UPIN