Healthcare Provider Details

I. General information

NPI: 1619090610
Provider Name (Legal Business Name): CROWN CITY MEDICAL GROUP INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3208 SANTA ANITA AVE # 200
EL MONTE CA
91733-1360
US

IV. Provider business mailing address

3208 SANTA ANITA AVE # 200
EL MONTE CA
91733-1360
US

V. Phone/Fax

Practice location:
  • Phone: 626-454-1990
  • Fax: 626-454-1995
Mailing address:
  • Phone: 626-454-1990
  • Fax: 626-454-1995

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: MAUREEN B. TYSON
Title or Position: CEO
Credential:
Phone: 626-798-8792