Provider Demographics
NPI:1104184860
Name:CENTRAL OCCUPATIONAL MEDICINE PROVIDERS - ONTARIO, A MEDICAL CORPORATI
Entity Type:Organization
Organization Name:CENTRAL OCCUPATIONAL MEDICINE PROVIDERS - ONTARIO, A MEDICAL CORPORATI
Other - Org Name:COMP
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:SPEER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-222-2206
Mailing Address - Street 1:4300 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-2918
Mailing Address - Country:US
Mailing Address - Phone:951-222-2206
Mailing Address - Fax:951-222-2196
Practice Address - Street 1:13800 HEACOCK ST
Practice Address - Street 2:SUITE C136
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-3339
Practice Address - Country:US
Practice Address - Phone:951-656-6009
Practice Address - Fax:951-656-6010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-01
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA48324207Q00000X
CAA43039207Q00000X
CA20A5982207Q00000X
CA48512207R00000X
CAG70519208D00000X
CA20A9190208D00000X
CAG72529208D00000X
261QX0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty