Healthcare Provider Details

I. General information

NPI: 1366864654
Provider Name (Legal Business Name): CHAPARRAL SPECIALTY MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2014
Last Update Date: 08/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1904 N ORANGE GROVE AVE
POMONA CA
91767-3008
US

IV. Provider business mailing address

840 TOWNE CENTER DR
POMONA CA
91767-5900
US

V. Phone/Fax

Practice location:
  • Phone: 909-469-1823
  • Fax: 909-469-1827
Mailing address:
  • Phone: 909-398-1550
  • Fax: 909-398-1573

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: ADRIENNE WALKER
Title or Position: CONTRACTS MANAGER
Credential:
Phone: 909-398-1550