Provider Demographics
NPI:1417578790
Name:INLAND EMPIRE MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:INLAND EMPIRE MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:OLIVEIRA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:909-581-5447
Mailing Address - Street 1:219 CALLE MORENO
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-3970
Mailing Address - Country:US
Mailing Address - Phone:909-581-5447
Mailing Address - Fax:
Practice Address - Street 1:506 W GRAHAM AVE STE 107
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-3665
Practice Address - Country:US
Practice Address - Phone:909-581-5447
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-28
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty