Healthcare Provider Details

I. General information

NPI: 1437601879
Provider Name (Legal Business Name): OUR FAMILY MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2016
Last Update Date: 11/13/2025
Certification Date: 11/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9190 HAVEN AVE STE 102
RANCHO CUCAMONGA CA
91730-5431
US

IV. Provider business mailing address

840 TOWNE CENTER DR
POMONA CA
91767-5900
US

V. Phone/Fax

Practice location:
  • Phone: 909-981-0989
  • Fax: 909-949-6214
Mailing address:
  • Phone: 909-398-1550
  • Fax: 909-398-0128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State

VIII. Authorized Official

Name: EWA H KONCA
Title or Position: PHYSICIAN
Credential:
Phone: 909-981-0989