Provider Demographics
NPI:1154317584
Name:FOOTHILLS NEUROLOGICAL MEDICAL GP
Entity Type:Organization
Organization Name:FOOTHILLS NEUROLOGICAL MEDICAL GP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:GAIL
Authorized Official - Middle Name:E
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:ADMINISTRATOR
Authorized Official - Phone:909-592-2145
Mailing Address - Street 1:1330 W COVINA BLVD
Mailing Address - Street 2:#103
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-3200
Mailing Address - Country:US
Mailing Address - Phone:909-592-2145
Mailing Address - Fax:909-599-6217
Practice Address - Street 1:1330 W COVINA BLVD
Practice Address - Street 2:#103
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-3200
Practice Address - Country:US
Practice Address - Phone:909-592-2145
Practice Address - Fax:909-599-6217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA334062084N0400X
CAA435232084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
Not Answered2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child NeurologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A334060Medicaid
CA00A435230Medicaid
W11191AMedicare ID - Type Unspecified
CA00A435230Medicaid
A17660Medicare UPIN