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General NPI Number Information
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NPI Number | 1851007173
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Entity Type | Organization
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Legal Business Name | OG MOBILE MEDICAL GROUP
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Dates
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Enumeration Date | 01/30/2023
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Last Update Date | 01/30/2023
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Provider Practice Location Address
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Address Line | 8972 APPALOOSA CT
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City | RANCHO CUCAMONGA
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State | CA
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Zip | 91737-1401
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Country | US
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Telephone | 909-274-9143
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Fax | 909-294-5911
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Provider Business Mailing Address
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Address Line | PO BOX 8896
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City | ALTA LOMA
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State | CA
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Zip | 91701-0896
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Country | US
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Telephone | 909-274-9143
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Fax | 909-295-5911
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Authorized Official
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Title or Position | OWNER
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Name | STEPHANIE CLARK-POVEDA
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Credential | PA
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Telephone | 909-274-9143
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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