MEDICARE: POMONA VALLEY COMMUNITY HEALTH CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center	COMMUNITY CLINIC	CA
2	261QC1500X	Community Health Clinic/Center	COMMUNITY CLINIC	CA

General Provider Information

NPI Number	:	1043565096
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	POMONA VALLEY COMMUNITY HEALTH CENTER

Provider Business Mailing Address
First Line	:	1568 N ORANGE GROVE AVE STE A
Second Line	:
City	:	POMONA
State	:	CA
Zip	:	91767-3812
Country	:	US
Telephone Number	:	909-868-6666
Fax Number	:	909-868-0206

Provider Business Practice Location Address
First Line	:	1568 N ORANGE GROVE AVE STE A
Second Line	:
City	:	POMONA
State	:	CA
Zip	:	91767-3812
Country	:	US
Telephone Number	:	909-868-6666
Fax Number	:	909-868-0206

Authorized Official
Title or Position	:	ADMINISTRATION
Name	:	LAURA DI SARLI
Credential	:
Telephone Number	:	909-868-6666

Provider Enumeration Date	:	07/16/2012
Last Update Date	:	07/16/2012

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