Healthcare Provider Details

I. General information

NPI: 1962486993
Provider Name (Legal Business Name): CHINO PEDIATRIC MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2005
Last Update Date: 07/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15944 LOS SERRANOS COUNTRY CLUB DR SUITE 220
CHINO HILLS CA
91709-3991
US

IV. Provider business mailing address

15944 LOS SERRANOS COUNTRY CLUB DR SUITE 220
CHINO HILLS CA
91709-3991
US

V. Phone/Fax

Practice location:
  • Phone: 909-393-6202
  • Fax: 909-393-6204
Mailing address:
  • Phone: 909-393-6202
  • Fax: 909-363-6204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number27982
License Number StateCA

VIII. Authorized Official

Name: DARYL K TSAI
Title or Position: TREASURER
Credential: M.D.
Phone: 909-393-6202