Healthcare Provider Details

I. General information

NPI: 1295270254
Provider Name (Legal Business Name): INLAND EMPIRE WOMANS CENTER, MEDICAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2016
Last Update Date: 03/26/2024
Certification Date: 03/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 WESTERN AVE STE 204
SAN BERNARDINO CA
92411-1353
US

IV. Provider business mailing address

1800 N. WESTERN AVE SUITE 204
SAN BERNARDINO CA
92411
US

V. Phone/Fax

Practice location:
  • Phone: 909-474-9952
  • Fax: 909-474-9951
Mailing address:
  • Phone: 909-474-9952
  • Fax: 909-474-9951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberA109432
License Number StateCA

VIII. Authorized Official

Name: JEFFREY RYAN LANGDON
Title or Position: CEO
Credential:
Phone: 909-474-9952