Provider Demographics
NPI:1730360579
Name:CLINICA MEDICA CENTRO HISPANO INC
Entity type:Organization
Organization Name:CLINICA MEDICA CENTRO HISPANO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MIGUEL
Authorized Official - Middle Name:I
Authorized Official - Last Name:DOMINGO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-467-1445
Mailing Address - Street 1:360 E 7TH ST STE H
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-6701
Mailing Address - Country:US
Mailing Address - Phone:909-985-8031
Mailing Address - Fax:909-985-8182
Practice Address - Street 1:360 E 7TH ST STE H
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-6701
Practice Address - Country:US
Practice Address - Phone:909-985-8031
Practice Address - Fax:909-985-8182
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-20
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA53766208000000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ53072YOtherBLUE SHIELD
CA1730360579Medicaid
CA1730360579Medicaid