Healthcare Provider Details

I. General information

NPI: 1043565096
Provider Name (Legal Business Name): POMONA VALLEY COMMUNITY HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2012
Last Update Date: 07/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1568 N ORANGE GROVE AVE STE A
POMONA CA
91767-3812
US

IV. Provider business mailing address

1568 N ORANGE GROVE AVE STE A
POMONA CA
91767-3812
US

V. Phone/Fax

Practice location:
  • Phone: 909-868-6666
  • Fax: 909-868-0206
Mailing address:
  • Phone: 909-868-6666
  • Fax: 909-868-0206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License NumberCOMMUNITY CLINIC
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberCOMMUNITY CLINIC
License Number StateCA

VIII. Authorized Official

Name: LAURA DI SARLI
Title or Position: ADMINISTRATION
Credential:
Phone: 909-868-6666