Provider Demographics
NPI:1104856947
Name:SAN DIMAS FAMILY CARE INC.
Entity Type:Organization
Organization Name:SAN DIMAS FAMILY CARE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CLIFFORD
Authorized Official - Middle Name:L
Authorized Official - Last Name:SUSSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-599-9921
Mailing Address - Street 1:150 W. FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-1102
Mailing Address - Country:US
Mailing Address - Phone:909-599-9921
Mailing Address - Fax:909-592-3147
Practice Address - Street 1:150 W. FOOTHILL BLVD.
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-1102
Practice Address - Country:US
Practice Address - Phone:909-599-9921
Practice Address - Fax:909-592-3147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW13176Medicare ID - Type UnspecifiedMC GROUP
W13176Medicare PIN