Provider Demographics
NPI:1164668786
Name:PREMIER FAMILY MEDICINE ASSOCIATES, INC
Entity Type:Organization
Organization Name:PREMIER FAMILY MEDICINE ASSOCIATES, INC
Other - Org Name:PVHC AT CLAREMONT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DUANE
Authorized Official - Middle Name:W
Authorized Official - Last Name:STYLES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-630-7938
Mailing Address - Street 1:1601 MONTE VISTA AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:CLAREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:91711-6601
Mailing Address - Country:US
Mailing Address - Phone:909-630-7938
Mailing Address - Fax:909-469-2118
Practice Address - Street 1:1601 MONTE VISTA AVE STE 100
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-6601
Practice Address - Country:US
Practice Address - Phone:909-630-7938
Practice Address - Fax:909-469-2118
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PREMIER FAMILY MEDICINE ASSOCIATES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-01-02
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
CA550000880261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00320034OtherSTATE OF CALIFORNIA CLP
05D0881917OtherCLIA
CA1164668786Medicaid
CAGR0083730Medicaid
CA550000880OtherDHS LICENSE