MEDICARE: INLAND CENTER MEDICAL GROUP, P.C.

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	261QM1300X	Multi-Specialty Clinic/Center

General Provider Information

NPI Number	:	1487613766
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INLAND CENTER MEDICAL GROUP, P.C.

Provider Business Mailing Address
First Line	:	8330 RED OAK STREET
Second Line	:	SUITE 101
City	:	RANCHO CUCAMONGA
State	:	CA
Zip	:	91730-0603
Country	:	US
Telephone Number	:	909-989-7551
Fax Number	:	909-945-5427

Provider Business Practice Location Address
First Line	:	8330 RED OAK STREET
Second Line	:	SUITE 101
City	:	RANCHO CUCAMONGA
State	:	CA
Zip	:	91730-0603
Country	:	US
Telephone Number	:	909-989-7551
Fax Number	:	909-945-5427

Authorized Official
Title or Position	:	OWNER
Name	:	DHARMESH S. MEHTA
Credential	:	MD
Telephone Number	:	909-989-7551

Provider Enumeration Date	:	03/23/2006
Last Update Date	:	06/03/2010

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