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General NPI Number Information
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NPI Number | 1669889986
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Entity Type | Organization
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Legal Business Name | KAISER FONTANA
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Dates
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Enumeration Date | 07/18/2014
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Last Update Date | 07/18/2014
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Provider Practice Location Address
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Address Line | 9961 SIERRA AVE
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City | FONTANA
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State | CA
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Zip | 92335-6720
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Country | US
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Telephone | 801-791-4514
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Fax |
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Provider Business Mailing Address
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Address Line | 1607 INDEPENDENCE AVE
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City | REDLANDS
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State | CA
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Zip | 92374
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Country | US
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Telephone | 801-791-4514
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | NOC PHAM
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Credential | MDA
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Telephone | 909-427-5000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number | 806523
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 284300000X
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Taxonomy Name | Special Hospital
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License Number | 806523
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License Number State | CA
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