=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831602655
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALL UNITED MEDICAL GROUP IPA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2017
-----------------------------------------------------
Last Update Date | 11/15/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 301 S LA CADENA DR
-----------------------------------------------------
City | COLTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92324-3419
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-219-5260
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 301 S LA CADENA DR
-----------------------------------------------------
City | COLTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92324-3419
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-219-5260
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | OCTAVIO RUIZ-VILLALPANDO
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 909-219-5260
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | A92039
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------