Healthcare Provider Details

I. General information

NPI: 1609887322
Provider Name (Legal Business Name): EXECUTIVE MEDICAL & SURGICAL ASSOC. INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 E WASHINGTON ST STE 200
COLTON CA
92324-4192
US

IV. Provider business mailing address

1040 S. MT. VERNON AVE. #G350
COLTON CA
92324
US

V. Phone/Fax

Practice location:
  • Phone: 909-824-2422
  • Fax: 909-824-8234
Mailing address:
  • Phone: 909-824-2422
  • Fax: 909-824-8234

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA72267
License Number StateCA

VIII. Authorized Official

Name: DARREN L BERGEY
Title or Position: PRESIDENT
Credential: M.D.
Phone: 909-824-2422