Healthcare Provider Details

I. General information

NPI: 1396960357
Provider Name (Legal Business Name): JOY OFO PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 07/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9057 CENTRAL AVE
MONTCLAIR CA
91763-1622
US

IV. Provider business mailing address

2619 SOUTH LASSEN AVE
ONTARIO CA
91761
US

V. Phone/Fax

Practice location:
  • Phone: 909-370-1777
  • Fax: 909-370-1776
Mailing address:
  • Phone: 909-370-1777
  • Fax: 909-370-1776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA18372
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: