MEDICARE: J KAGWA-NYANZI PEDIATRICS CLINIC INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	A45809	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1073741039
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	J KAGWA-NYANZI PEDIATRICS CLINIC INC

Provider Business Mailing Address
First Line	:	117 W WILLOW ST STE B
Second Line	:
City	:	POMONA
State	:	CA
Zip	:	91768-1829
Country	:	US
Telephone Number	:	909-865-5519
Fax Number	:

Provider Business Practice Location Address
First Line	:	117 W WILLOW ST STE B
Second Line	:
City	:	POMONA
State	:	CA
Zip	:	91768-1829
Country	:	US
Telephone Number	:	909-865-5519
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	JUANITA KAGWA
Credential	:	MD
Telephone Number	:	909-865-5519

Provider Enumeration Date	:	06/29/2009
Last Update Date	:	06/29/2009

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