Healthcare Provider Details

I. General information

NPI: 1376801696
Provider Name (Legal Business Name): SURGICAL GROUP OF THE INLAND EMPIRE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2012
Last Update Date: 04/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8680 MONROE CT STE 150
RANCHO CUCAMONGA CA
91730-4881
US

IV. Provider business mailing address

8680 MONROE CT STE 150
RANCHO CUCAMONGA CA
91730-4881
US

V. Phone/Fax

Practice location:
  • Phone: 909-987-0899
  • Fax:
Mailing address:
  • Phone: 909-579-3111
  • Fax: 909-204-4197

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JACOB HAIAVY
Title or Position: OWNER
Credential: MD
Phone: 909-579-3111