Healthcare Provider Details

I. General information

NPI: 1174284509
Provider Name (Legal Business Name): JMK MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2022
Last Update Date: 10/06/2022
Certification Date: 10/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 KENDALL DR STE F
SAN BERNARDINO CA
92407-4125
US

IV. Provider business mailing address

6855 PORTOFINO CT
RANCHO CUCAMONGA CA
91701-8637
US

V. Phone/Fax

Practice location:
  • Phone: 909-352-6655
  • Fax: 909-352-6770
Mailing address:
  • Phone: 909-352-6655
  • Fax: 909-352-6770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083C0008X
TaxonomyClinical Informatics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. NKOLI ANIGBOGU
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 909-352-6655