Healthcare Provider Details

I. General information

NPI: 1699722744
Provider Name (Legal Business Name): CHANNELL FAMILY MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 04/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8008 HAVEN AVE SUITE 100
RANCHO CUCAMONGA CA
91730-3070
US

IV. Provider business mailing address

8008 HAVEN AVE SUITE 100
RANCHO CUCAMONGA CA
91730-3070
US

V. Phone/Fax

Practice location:
  • Phone: 909-483-1236
  • Fax: 909-483-1463
Mailing address:
  • Phone: 909-483-1236
  • Fax: 909-483-1463

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: PATRICIA GUEVARA-CHANNELL
Title or Position: OWNER
Credential: M.D.
Phone: 909-483-7836