Provider Demographics
NPI:1164175410
Name:UPLAND-ONTARIO MEDICAL CLINIC INC
Entity Type:Organization
Organization Name:UPLAND-ONTARIO MEDICAL CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:NAGASAMUDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:ASHOK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-949-9299
Mailing Address - Street 1:1520 N MOUNTAIN AVE STE 128
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91762-1132
Mailing Address - Country:US
Mailing Address - Phone:909-949-9299
Mailing Address - Fax:909-949-9029
Practice Address - Street 1:1520 N MOUNTAIN AVE STE 128
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91762-1132
Practice Address - Country:US
Practice Address - Phone:909-949-9299
Practice Address - Fax:909-949-9029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-27
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty