Provider Demographics
NPI:1174284509
Name:JMK MEDICAL CLINIC
Entity Type:Organization
Organization Name:JMK MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:NKOLI
Authorized Official - Middle Name:
Authorized Official - Last Name:ANIGBOGU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-352-6655
Mailing Address - Street 1:6855 PORTOFINO CT
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91701-8637
Mailing Address - Country:US
Mailing Address - Phone:909-352-6655
Mailing Address - Fax:909-352-6770
Practice Address - Street 1:1050 KENDALL DR STE F
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92407-4125
Practice Address - Country:US
Practice Address - Phone:909-352-6655
Practice Address - Fax:909-352-6770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-07
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No2083C0008XAllopathic & Osteopathic PhysiciansPreventive MedicineClinical InformaticsGroup - Single Specialty