=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316072754
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLAREMONT COMMUNITY CARE CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/23/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1996 INDIAN HILL BLVD
-----------------------------------------------------
City | POMONA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91767-3620
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-670-0777
-----------------------------------------------------
Fax | 909-670-0157
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1996 INDIAN HILL BLVD
-----------------------------------------------------
City | POMONA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91767-3620
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-670-0777
-----------------------------------------------------
Fax | 909-670-0157
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MARIA OLAGUEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 909-670-0777
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------