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NPI Code Detail

MEDICARE: INLAND EMPIRE MEDICAL GROUP, INC

MEDICARE: INLAND EMPIRE MEDICAL GROUP, INC
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
1208D00000XGeneral Practice Physician
2261QP2300XPrimary Care Clinic/Center

General Provider Information

NPI Number : 1417578790
Entity Type Code : Organization
Provider Name (Legal Business Name) : INLAND EMPIRE MEDICAL GROUP, INC
Provider Business Mailing Address
First Line : 219 CALLE MORENO
Second Line :
City : SAN DIMAS
State : CA
Zip : 91773-3970
Country : US
Telephone Number : 909-581-5447
Fax Number :
Provider Business Practice Location Address
First Line : 506 W GRAHAM AVE STE 107
Second Line :
City : LAKE ELSINORE
State : CA
Zip : 92530-3665
Country : US
Telephone Number : 909-581-5447
Fax Number :
Authorized Official
Title or Position : MEDICAL DIRECTOR
Name : THOMAS OLIVEIRA
Credential : DO
Telephone Number : 909-581-5447
Provider Enumeration Date : 04/28/2020
Last Update Date : 04/28/2020

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Directions to “INLAND EMPIRE MEDICAL GROUP, INC ” Practice Location

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