Provider Demographics
NPI:1033634373
Name:PREMIER FAMILY MEDICINE ASSOCIATES, INC
Entity Type:Organization
Organization Name:PREMIER FAMILY MEDICINE ASSOCIATES, INC
Other - Org Name:PVHC@ LAVERNE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DEANDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-865-9501
Mailing Address - Street 1:1601 MONTE VISTA AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:CLAREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:91711-6601
Mailing Address - Country:US
Mailing Address - Phone:909-865-9501
Mailing Address - Fax:909-946-0211
Practice Address - Street 1:2333 FOOTHILL BLVD STE B
Practice Address - Street 2:
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750-3027
Practice Address - Country:US
Practice Address - Phone:909-392-6501
Practice Address - Fax:909-469-2136
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PREMIER FAMILY MEDICINE ASSOCIATES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-08-08
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth ServiceGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1033634373Medicaid