Provider Demographics
NPI:1013214568
Name:LAS PALMAS MEDICAL GROUP CORP.
Entity Type:Organization
Organization Name:LAS PALMAS MEDICAL GROUP CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:IRMA
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-391-3448
Mailing Address - Street 1:602 N EUCLID AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91762-3224
Mailing Address - Country:US
Mailing Address - Phone:909-391-3448
Mailing Address - Fax:
Practice Address - Street 1:602 N EUCLID AVE
Practice Address - Street 2:SUITE A
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91762-3224
Practice Address - Country:US
Practice Address - Phone:909-391-3448
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-18
Last Update Date:2011-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG57022208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1770663551Medicaid
CA1164503652Medicaid
CAW17224Medicare PIN
CAE56204Medicare UPIN