Healthcare Provider Details

I. General information

NPI: 1457269136
Provider Name (Legal Business Name): AVITALITY MEDICAL PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2026
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

653 E E ST STE 109
ONTARIO CA
91764-4257
US

IV. Provider business mailing address

653 E E ST STE 109
ONTARIO CA
91764-4257
US

V. Phone/Fax

Practice location:
  • Phone: 909-395-9888
  • Fax:
Mailing address:
  • Phone: 909-395-9888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number
License Number State

VIII. Authorized Official

Name: LAN LAM
Title or Position: OWNER
Credential: PAC
Phone: 909-395-9888