Healthcare Provider Details

I. General information

NPI: 1023295458
Provider Name (Legal Business Name): VALLEY WIDE MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2008
Last Update Date: 06/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12500 BORON AVE
BORON CA
93730
US

IV. Provider business mailing address

12500 BORON AVE
BORON CA
93730
US

V. Phone/Fax

Practice location:
  • Phone: 760-762-5111
  • Fax: 760-762-5695
Mailing address:
  • Phone: 760-762-5111
  • Fax: 760-762-5695

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA89858
License Number StateCA

VIII. Authorized Official

Name: PRABHAKAR TUMMALA
Title or Position: PRESIDENT
Credential: MD
Phone: 909-945-7687