Provider Demographics
NPI:1366447781
Name:HOLLENBERG AGRAWAL KNOLL WARREN HONG FUNG TILLIS KAUSHAL MDS
Entity Type:Organization
Organization Name:HOLLENBERG AGRAWAL KNOLL WARREN HONG FUNG TILLIS KAUSHAL MDS
Other - Org Name:POMONA PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:STAFF/IT
Authorized Official - Prefix:MR
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-620-1935
Mailing Address - Street 1:250 W BONITA AVE
Mailing Address - Street 2:#200
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-1850
Mailing Address - Country:US
Mailing Address - Phone:909-620-1935
Mailing Address - Fax:909-865-7688
Practice Address - Street 1:250 W BONITA AVE
Practice Address - Street 2:#200
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-1850
Practice Address - Country:US
Practice Address - Phone:909-620-1935
Practice Address - Fax:909-865-7688
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-14
Last Update Date:2014-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0066720OtherMEDI CAL GROUP NUMBER