Provider Demographics
NPI:1407082159
Name:SOUTHERN CALIFORNIA ORTHOPEDIC MEDICAL GROUP INC
Entity Type:Organization
Organization Name:SOUTHERN CALIFORNIA ORTHOPEDIC MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:J
Authorized Official - Last Name:MILES
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:909-941-3986
Mailing Address - Street 1:3602 INLAND EMPIRE BLVD
Mailing Address - Street 2:SUITE B 120
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91764-4900
Mailing Address - Country:US
Mailing Address - Phone:909-941-3986
Mailing Address - Fax:909-941-3988
Practice Address - Street 1:3602 INLAND EMPIRE BLVD
Practice Address - Street 2:SUITE B 120
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91764-4900
Practice Address - Country:US
Practice Address - Phone:909-941-3986
Practice Address - Fax:909-941-3988
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-09
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic SurgeryGroup - Multi-Specialty