Healthcare Provider Details

I. General information

NPI: 1184366973
Provider Name (Legal Business Name): SRK CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2022
Last Update Date: 04/12/2022
Certification Date: 04/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10808 FOOTHILL BLVD # 635
RANCHO CUCAMONGA CA
91730-3889
US

IV. Provider business mailing address

10808 FOOTHILL BLVD # 635
RANCHO CUCAMONGA CA
91730-3889
US

V. Phone/Fax

Practice location:
  • Phone: 626-316-8915
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number
License Number State

VIII. Authorized Official

Name: STACEEY KEY
Title or Position: OWNER
Credential: CPT1
Phone: 626-316-8915