Provider Demographics
NPI:1376801696
Name:SURGICAL GROUP OF THE INLAND EMPIRE
Entity Type:Organization
Organization Name:SURGICAL GROUP OF THE INLAND EMPIRE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:HAIAVY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-579-3111
Mailing Address - Street 1:8680 MONROE CT
Mailing Address - Street 2:STE 150
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-4881
Mailing Address - Country:US
Mailing Address - Phone:909-579-3111
Mailing Address - Fax:909-204-4197
Practice Address - Street 1:8680 MONROE CT
Practice Address - Street 2:STE 150
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-4881
Practice Address - Country:US
Practice Address - Phone:909-987-0899
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-24
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center