Healthcare Provider Details

I. General information

NPI: 1033389408
Provider Name (Legal Business Name): RANCHO INDUSTRIAL MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2008
Last Update Date: 03/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14384 SLOVER AVE
FONTANA CA
92337-7122
US

IV. Provider business mailing address

14384 SLOVER AVE
FONTANA CA
92337-7122
US

V. Phone/Fax

Practice location:
  • Phone: 909-350-7208
  • Fax: 909-350-7209
Mailing address:
  • Phone: 909-350-7208
  • Fax: 909-350-7209

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number18783
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number20771
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number27592
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA37952
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG39074
License Number StateCA

VIII. Authorized Official

Name: DR. EDUARDO E ANGUIZOLA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 909-350-7208