Provider Demographics
NPI:1235589086
Name:JOSE DE LA LLANA M.D.. INC
Entity Type:Organization
Organization Name:JOSE DE LA LLANA M.D.. INC
Other - Org Name:SU CLINICA MEDICA MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC ADMISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GABRIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PULGARIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-886-7576
Mailing Address - Street 1:850 W HIGHLAND AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92405-3855
Mailing Address - Country:US
Mailing Address - Phone:909-886-7576
Mailing Address - Fax:909-882-4921
Practice Address - Street 1:850 W HIGHLAND AVE
Practice Address - Street 2:SUITE A
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92405-3855
Practice Address - Country:US
Practice Address - Phone:909-886-7576
Practice Address - Fax:909-882-4921
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-13
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA101657208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty