Provider Demographics
NPI:1619622636
Name:JENNIFER COBANOV, MD PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:JENNIFER COBANOV, MD PROFESSIONAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:COBANOV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-647-8783
Mailing Address - Street 1:PO BOX 902
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-0902
Mailing Address - Country:US
Mailing Address - Phone:909-647-8783
Mailing Address - Fax:
Practice Address - Street 1:414 TENNESSEE ST STE K1
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-8152
Practice Address - Country:US
Practice Address - Phone:909-531-4427
Practice Address - Fax:909-288-4731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-17
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty