Provider Demographics
NPI:1457469884
Name:LA VERNE FAMILY MEDICAL CENTER INC
Entity Type:Organization
Organization Name:LA VERNE FAMILY MEDICAL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TAN
Authorized Official - Middle Name:LIN
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-596-1941
Mailing Address - Street 1:2100 FOOTHILL BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-2905
Mailing Address - Country:US
Mailing Address - Phone:909-596-1941
Mailing Address - Fax:909-596-1943
Practice Address - Street 1:2100 FOOTHILL BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750-2905
Practice Address - Country:US
Practice Address - Phone:909-596-1941
Practice Address - Fax:909-596-1943
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-27
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA50496207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW20443OtherMEDICARE GROUP ID
CAWA504960Medicare PIN
CAF74579Medicare UPIN
CAW20443OtherMEDICARE GROUP ID