Healthcare Provider Details

I. General information

NPI: 1497809297
Provider Name (Legal Business Name): CMG CLINICAL LABORATORY AND ANCILLARY SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 11/13/2023
Certification Date: 09/25/2023
Deactivation Date: 03/10/2023
Reactivation Date: 06/06/2023

III. Provider practice location address

1866 N ORANGE GROVE AVE SUITE #101
POMONA CA
91767-3031
US

IV. Provider business mailing address

840 TOWNE CENTER DR
POMONA CA
91767-5900
US

V. Phone/Fax

Practice location:
  • Phone: 909-622-8451
  • Fax: 909-620-2560
Mailing address:
  • Phone: 909-398-1550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207UN0902X
TaxonomyNuclear Imaging & Therapy Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License Number
License Number State

VIII. Authorized Official

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