Healthcare Provider Details

I. General information

NPI: 1942793658
Provider Name (Legal Business Name): JDCM CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2018
Last Update Date: 06/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1749 S EUCLID AVE STE A
ONTARIO CA
91762-5832
US

IV. Provider business mailing address

1749 S EUCLID AVE STE A
ONTARIO CA
91762-5832
US

V. Phone/Fax

Practice location:
  • Phone: 909-972-0300
  • Fax: 909-984-4878
Mailing address:
  • Phone: 909-972-0300
  • Fax: 909-984-4878

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CORAZON C MANAPAT
Title or Position: PRESIDENT
Credential: FNP
Phone: 909-972-0300