Healthcare Provider Details

I. General information

NPI: 1619380896
Provider Name (Legal Business Name): PACIFIC BREAST INSTITUTE MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2014
Last Update Date: 06/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 VINTON AVE SUITE 202
POMONA CA
91767-3000
US

IV. Provider business mailing address

20160 E LIMECREST DR
COVINA CA
91724-3945
US

V. Phone/Fax

Practice location:
  • Phone: 909-629-6417
  • Fax: 909-629-4755
Mailing address:
  • Phone: 909-629-6417
  • Fax: 909-629-4755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberA26396
License Number StateCA

VIII. Authorized Official

Name: DR. OSSAMA DEAYA ASCHA
Title or Position: PRESIDENT
Credential: MD
Phone: 909-629-6417