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General NPI Number Information
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NPI Number | 1104127109
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Entity Type | Organization
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Legal Business Name | CLINICA DEL PUEBLO MEDICAL GROUP CORP
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Dates
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Enumeration Date | 11/06/2010
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Last Update Date | 11/06/2010
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Provider Practice Location Address
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Address Line | 10200 MAIN ST STE B
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City | LAMONT
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State | CA
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Zip | 93241-1700
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Country | US
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Telephone | 661-845-1788
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Fax | 661-845-1791
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Provider Business Mailing Address
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Address Line | 10200 MAIN ST STE B
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City | LAMONT
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State | CA
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Zip | 93241-1700
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Country | US
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Telephone | 661-845-1788
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Fax | 661-845-1791
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Authorized Official
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Title or Position | DIRECTOR
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Name | DR. SAM N RATNAYAKE
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Credential | MD
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Telephone | 661-377-3777
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | A056363
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License Number State | CA
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