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General NPI Number Information
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NPI Number | 1134731482
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Entity Type | Organization
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Legal Business Name | BORROMEO III MD A MEDICAL CORPORATION
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Dates
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Enumeration Date | 08/18/2020
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Last Update Date | 08/18/2020
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Provider Practice Location Address
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Address Line | 3218 E HOLT AVE STE 200
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City | WEST COVINA
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State | CA
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Zip | 91791-2310
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Country | US
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Telephone | 562-414-4222
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Fax | 562-865-0444
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Provider Business Mailing Address
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Address Line | 3218 E HOLT AVE STE 200
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City | WEST COVINA
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State | CA
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Zip | 91791-2310
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Country | US
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Telephone | 562-414-4222
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Fax | 562-865-0444
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Authorized Official
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Title or Position | CREDENTIALING MANAGER
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Name | JENNY BRAGANZA
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Credential |
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Telephone | 562-414-4222
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RC0000X
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Taxonomy Name | Cardiovascular Disease Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State |
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