Healthcare Provider Details

I. General information

NPI: 1851007173
Provider Name (Legal Business Name): OG MOBILE MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2023
Last Update Date: 01/30/2023
Certification Date: 01/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8972 APPALOOSA CT
RANCHO CUCAMONGA CA
91737-1401
US

IV. Provider business mailing address

PO BOX 8896
ALTA LOMA CA
91701-0896
US

V. Phone/Fax

Practice location:
  • Phone: 909-274-9143
  • Fax: 909-294-5911
Mailing address:
  • Phone: 909-274-9143
  • Fax: 909-295-5911

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 Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: STEPHANIE CLARK-POVEDA
Title or Position: OWNER
Credential: PA
Phone: 909-274-9143