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General NPI Number Information
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NPI Number | 1174284509
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Entity Type | Organization
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Legal Business Name | JMK MEDICAL CLINIC
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Dates
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Enumeration Date | 01/07/2022
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Last Update Date | 10/06/2022
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Provider Practice Location Address
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Address Line | 1050 KENDALL DR STE F
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City | SAN BERNARDINO
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State | CA
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Zip | 92407-4125
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Country | US
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Telephone | 909-352-6655
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Fax | 909-352-6770
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Provider Business Mailing Address
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Address Line | 6855 PORTOFINO CT
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City | RANCHO CUCAMONGA
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State | CA
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Zip | 91701-8637
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Country | US
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Telephone | 909-352-6655
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Fax | 909-352-6770
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. NKOLI ANIGBOGU
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Credential | MD
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Telephone | 909-352-6655
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2083C0008X
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Taxonomy Name | Clinical Informatics 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 | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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