Provider Demographics
NPI:1104043835
Name:FOOTHILL COMMUNITY MEDICAL CORPORATION
Entity Type:Organization
Organization Name:FOOTHILL COMMUNITY MEDICAL CORPORATION
Other - Org Name:SAN RAFAEL COMMUNITY MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAFAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:CARCAMO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-865-2538
Mailing Address - Street 1:1126 W MISSION BLVD
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91766-1342
Mailing Address - Country:US
Mailing Address - Phone:909-865-2538
Mailing Address - Fax:909-865-2508
Practice Address - Street 1:1126 W MISSION BLVD
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91766-1342
Practice Address - Country:US
Practice Address - Phone:909-865-2538
Practice Address - Fax:909-865-2508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00A666750207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0090561Medicaid
CAW15381Medicare ID - Type UnspecifiedGROUP