Healthcare Provider Details

I. General information

NPI: 1477167062
Provider Name (Legal Business Name): CLINICA DEL PUEBLO CARCAMO A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2020
Last Update Date: 09/02/2020
Certification Date: 09/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14650 PACIFIC AVE
BALDWIN PARK CA
91706-5333
US

IV. Provider business mailing address

14083 HASTINGS RANCH LN
RANCHO CUCAMONGA CA
91739-2112
US

V. Phone/Fax

Practice location:
  • Phone: 626-337-1360
  • Fax: 626-962-1375
Mailing address:
  • Phone: 951-285-4393
  • Fax: 760-948-6244

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. OCTAVIO RUIZ-VILLALPANDO
Title or Position: PRESIDENT/OWNER
Credential: MD
Phone: 909-815-1991