Healthcare Provider Details

I. General information

NPI: 1497783229
Provider Name (Legal Business Name): CUCAMONGA VALLEY MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 04/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16465 SIERRA LAKES PARKWAY #300
FONTANA CA
92336
US

IV. Provider business mailing address

16465 SIERRA LAKES PARKWAY #300
FONTANA CA
92336
US

V. Phone/Fax

Practice location:
  • Phone: 909-429-2864
  • Fax: 909-429-2868
Mailing address:
  • Phone: 909-429-2864
  • Fax: 909-429-2868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number858582
License Number StateME

VIII. Authorized Official

Name: DR. KYLE NELSON SMART
Title or Position: PRESIDENT
Credential: D.O.
Phone: 909-429-2864