Provider Demographics
NPI:1447561162
Name:ONTARIO FAMILY MEDICAL CENTER INC
Entity Type:Organization
Organization Name:ONTARIO FAMILY MEDICAL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:S
Authorized Official - Last Name:WILBUR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-483-1011
Mailing Address - Street 1:3700 E. INLAND EMPIRE BLVD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91764-4906
Mailing Address - Country:US
Mailing Address - Phone:909-483-1001
Mailing Address - Fax:909-483-1063
Practice Address - Street 1:3700 E. INLAND EMPIRE BLVD
Practice Address - Street 2:SUITE 250
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91764-4906
Practice Address - Country:US
Practice Address - Phone:909-483-1001
Practice Address - Fax:909-483-1063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-28
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3281697207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA3281697OtherSTATE BUSINESS LICENSE