MEDICARE: JMK MEDICAL CLINIC

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	2083C0008X	Clinical Informatics Physician
2	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1174284509
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JMK MEDICAL CLINIC

Provider Business Mailing Address
First Line	:	6855 PORTOFINO CT
Second Line	:
City	:	RANCHO CUCAMONGA
State	:	CA
Zip	:	91701-8637
Country	:	US
Telephone Number	:	909-352-6655
Fax Number	:	909-352-6770

Provider Business Practice Location Address
First Line	:	1050 KENDALL DR STE F
Second Line	:
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92407-4125
Country	:	US
Telephone Number	:	909-352-6655
Fax Number	:	909-352-6770

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. NKOLI ANIGBOGU
Credential	:	MD
Telephone Number	:	909-352-6655

Provider Enumeration Date	:	01/07/2022
Last Update Date	:	10/06/2022

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