Provider Demographics
NPI:1114374071
Name:COLTON CLINICA MEDICA FAMILIAR A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:COLTON CLINICA MEDICA FAMILIAR A MEDICAL CORPORATION
Other - Org Name:COLTON CLINICA MEDICA FAMILIAR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:OCTAVIO
Authorized Official - Middle Name:
Authorized Official - Last Name:RUIZ-VILLALPANDO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-285-4393
Mailing Address - Street 1:301 S LA CADENA DR
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-3419
Mailing Address - Country:US
Mailing Address - Phone:909-219-5093
Mailing Address - Fax:909-219-5260
Practice Address - Street 1:301 S LA CADENA DR
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-3419
Practice Address - Country:US
Practice Address - Phone:909-219-5093
Practice Address - Fax:909-219-5260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-20
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA92039207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty