Provider Demographics
NPI:1497182596
Name:ELITE MEDICAL GROUP
Entity Type:Organization
Organization Name:ELITE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:LIN
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:909-869-8501
Mailing Address - Street 1:20265 VALLEY BLVD STE E
Mailing Address - Street 2:
Mailing Address - City:WALNUT
Mailing Address - State:CA
Mailing Address - Zip Code:91789-2655
Mailing Address - Country:US
Mailing Address - Phone:909-869-8501
Mailing Address - Fax:909-869-8401
Practice Address - Street 1:20265 VALLEY BLVD STE E
Practice Address - Street 2:
Practice Address - City:WALNUT
Practice Address - State:CA
Practice Address - Zip Code:91789-2655
Practice Address - Country:US
Practice Address - Phone:909-869-8501
Practice Address - Fax:909-869-8401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-03
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty