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General NPI Number Information
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NPI Number | 1508580523
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Entity Type | Organization
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Legal Business Name | ALTA MEDICAL GROUP OF CALIFORNIA
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Dates
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Enumeration Date | 10/03/2022
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Last Update Date | 10/03/2022
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Provider Practice Location Address
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Address Line | 9836 FOOTHILL BLVD STE 610
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City | RANCHO CUCAMONGA
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State | CA
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Zip | 91730-3660
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Country | US
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Telephone | 909-236-0338
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Fax |
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Provider Business Mailing Address
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Address Line | 9836 FOOTHILL BLVD STE 610
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City | RANCHO CUCAMONGA
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State | CA
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Zip | 91730-3660
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Country | US
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Telephone | 909-236-0338
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | PETERSON GO
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Credential |
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Telephone | 909-236-0338
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084B0040X
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Taxonomy Name | Behavioral Neurology & Neuropsychiatry 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 | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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