Healthcare Provider Details

I. General information

NPI: 1154547065
Provider Name (Legal Business Name): KIDS COME FIRST COMMUNITY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 10/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1556 S SULTANA AVE
ONTARIO CA
91761-4238
US

IV. Provider business mailing address

1556 S SULTANA AVE
ONTARIO CA
91761-4238
US

V. Phone/Fax

Practice location:
  • Phone: 909-984-7384
  • Fax: 909-982-7268
Mailing address:
  • Phone: 909-984-7384
  • Fax: 909-984-7268

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number240000826
License Number StateCA

VIII. Authorized Official

Name: CYNTHIA PRENDIZ
Title or Position: PROGRAM COORDINATOR
Credential:
Phone: 909-984-7384