Healthcare Provider Details

I. General information

NPI: 1053350884
Provider Name (Legal Business Name): CHINO MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 12/12/2024
Certification Date: 12/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5475 WALNUT AVE
CHINO CA
91710-2609
US

IV. Provider business mailing address

5475 WALNUT AVE
CHINO CA
91710-2609
US

V. Phone/Fax

Practice location:
  • Phone: 909-591-6446
  • Fax: 909-591-1309
Mailing address:
  • Phone: 909-591-6446
  • Fax: 909-591-1309

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QE0800X
TaxonomyEndoscopy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: PRASAD JEEREDDI
Title or Position: CEO
Credential: MD
Phone: 909-591-6446