Provider Demographics
NPI:1326573437
Name:MONTE VISTA PHYSICIANS A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:MONTE VISTA PHYSICIANS A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRIMARY CARE PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:
Authorized Official - Last Name:DE LA LLANA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-931-0069
Mailing Address - Street 1:9625 MONTE VISTA AVE STE 108
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:CA
Mailing Address - Zip Code:91763-2200
Mailing Address - Country:US
Mailing Address - Phone:909-625-7784
Mailing Address - Fax:
Practice Address - Street 1:914 W FOOTHILL BLVD STE A
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-3785
Practice Address - Country:US
Practice Address - Phone:909-931-0069
Practice Address - Fax:909-625-4954
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-26
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA44835207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A448351Medicaid
CA00A448350Medicare UPIN