=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396926937
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | YIN-JIA GONG MEDICAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/26/2007
-----------------------------------------------------
Last Update Date | 08/17/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 112 N RIVERSIDE AVE
-----------------------------------------------------
City | RIALTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92376-5922
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-875-1212
-----------------------------------------------------
Fax | 909-498-7361
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 112 N RIVERSIDE AVE
-----------------------------------------------------
City | RIALTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92376-5922
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-875-1212
-----------------------------------------------------
Fax | 909-498-7361
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. YIN-JIA GONG
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 909-875-1212
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP3300X
-----------------------------------------------------
Taxonomy Name | Pain Clinic/Center
-----------------------------------------------------
License Number | A56519
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------