Healthcare Provider Details

I. General information

NPI: 1972861797
Provider Name (Legal Business Name): CENTRAL OCCUPATIONAL MEDICINE PROVIDERS ONTARIO INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2012
Last Update Date: 05/04/2020
Certification Date: 05/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 CENTRAL AVE
RIVERSIDE CA
92506-2918
US

IV. Provider business mailing address

4300 CENTRAL AVE
RIVERSIDE CA
92506-2918
US

V. Phone/Fax

Practice location:
  • Phone: 951-222-2206
  • Fax: 951-222-2196
Mailing address:
  • Phone: 951-222-2206
  • Fax: 951-222-2196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA48324
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC41297
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A5982
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA36269
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA48512
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA92637
License Number StateCA
# 7
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberG72529
License Number StateCA
# 8
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberG70519
License Number StateCA
# 9
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number20A9190
License Number StateCA
# 10
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA11255
License Number StateCA
# 11
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA52001
License Number StateCA
# 12
Primary TaxonomyY
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. GREGORY JOSEPH SPEER
Title or Position: ADMINISTRATOR
Credential:
Phone: 951-222-2206