MEDICARE: SOUTHERN CALIFORNIA INJURY TREATMENT CENTER, LLC

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	207X00000X	Orthopaedic Surgery Physician	G041089	CA

General Provider Information

NPI Number	:	1558676627
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN CALIFORNIA INJURY TREATMENT CENTER, LLC

Provider Business Mailing Address
First Line	:	14365 PIPELINE AVE
Second Line	:
City	:	CHINO
State	:	CA
Zip	:	91710-5642
Country	:	US
Telephone Number	:	909-364-8111
Fax Number	:	909-591-0538

Provider Business Practice Location Address
First Line	:	14365 PIPELINE AVE
Second Line	:
City	:	CHINO
State	:	CA
Zip	:	91710-5642
Country	:	US
Telephone Number	:	909-364-8111
Fax Number	:	909-591-0538

Authorized Official
Title or Position	:	ORTHOPEDIC SURGEON
Name	:	DR. CLYDE O. HARRIS III
Credential	:	M.D.
Telephone Number	:	909-364-8111

Provider Enumeration Date	:	08/13/2010
Last Update Date	:	08/13/2010

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