Healthcare Provider Details

I. General information

NPI: 1104184860
Provider Name (Legal Business Name): CENTRAL OCCUPATIONAL MEDICINE PROVIDERS - ONTARIO, A MEDICAL CORPORATI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2012
Last Update Date: 04/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13800 HEACOCK ST SUITE C136
MORENO VALLEY CA
92553-3339
US

IV. Provider business mailing address

4300 CENTRAL AVE
RIVERSIDE CA
92506-2918
US

V. Phone/Fax

Practice location:
  • Phone: 951-656-6009
  • Fax: 951-656-6010
Mailing address:
  • Phone: 951-222-2206
  • Fax: 951-222-2196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA48324
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA43039
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A5982
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number48512
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberG70519
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number20A9190
License Number StateCA
# 7
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberG72529
License Number StateCA
# 8
Primary TaxonomyY
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. GREGORY JOSEPH SPEER
Title or Position: ADMINISTRATOR
Credential:
Phone: 951-222-2206