MEDICARE: ALTA VIDA MEDICAL GROUP 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	207Q00000X	Family Medicine Physician
2	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1922954544
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALTA VIDA MEDICAL GROUP INC

Provider Business Mailing Address
First Line	:	12326 MERITAGE CT
Second Line	:
City	:	RANCHO CUCAMONGA
State	:	CA
Zip	:	91739-8825
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	363 S INDIAN HILL BLVD
Second Line	:
City	:	CLAREMONT
State	:	CA
Zip	:	91711-5224
Country	:	US
Telephone Number	:	909-816-7927
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	GEORGE MORAN
Credential	:	MD
Telephone Number	:	909-816-7927

Provider Enumeration Date	:	03/06/2026
Last Update Date	:	03/06/2026

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