Provider Demographics
NPI:1073741039
Name:J KAGWA-NYANZI PEDIATRICS CLINIC INC
Entity Type:Organization
Organization Name:J KAGWA-NYANZI PEDIATRICS CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JUANITA
Authorized Official - Middle Name:
Authorized Official - Last Name:KAGWA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-865-5519
Mailing Address - Street 1:117 W WILLOW ST STE B
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91768-1829
Mailing Address - Country:US
Mailing Address - Phone:909-865-5519
Mailing Address - Fax:
Practice Address - Street 1:117 W WILLOW ST STE B
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91768-1829
Practice Address - Country:US
Practice Address - Phone:909-865-5519
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-29
Last Update Date:2009-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA45809208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A458090Medicaid
CAA45809Medicare PIN