Healthcare Provider Details

I. General information

NPI: 1326573437
Provider Name (Legal Business Name): MONTE VISTA PHYSICIANS A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2017
Last Update Date: 01/24/2020
Certification Date: 01/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

914 W FOOTHILL BLVD STE A
UPLAND CA
91786-3785
US

IV. Provider business mailing address

9625 MONTE VISTA AVE STE 108
MONTCLAIR CA
91763-2200
US

V. Phone/Fax

Practice location:
  • Phone: 909-931-0069
  • Fax: 909-625-4954
Mailing address:
  • Phone: 909-625-7784
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA44835
License Number StateCA

VIII. Authorized Official

Name: DR. JOSE DE LA LLANA
Title or Position: PRIMARY CARE PROVIDER
Credential: M.D.
Phone: 909-931-0069