Healthcare Provider Details

I. General information

NPI: 1366447781
Provider Name (Legal Business Name): HOLLENBERG AGRAWAL KNOLL WARREN HONG FUNG TILLIS KAUSHAL MDS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2005
Last Update Date: 07/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 W BONITA AVE #200
POMONA CA
91767-1850
US

IV. Provider business mailing address

250 W BONITA AVE #200
POMONA CA
91767-1850
US

V. Phone/Fax

Practice location:
  • Phone: 909-620-1935
  • Fax: 909-865-7688
Mailing address:
  • Phone: 909-620-1935
  • Fax: 909-865-7688

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. JIM HOLLENBERG
Title or Position: STAFF/IT
Credential:
Phone: 909-620-1935