Provider Demographics
NPI:1497783229
Name:CUCAMONGA VALLEY MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:CUCAMONGA VALLEY MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:NELSON
Authorized Official - Last Name:SMART
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:909-429-2864
Mailing Address - Street 1:16465 SIERRA LAKES PARKWAY
Mailing Address - Street 2:#300
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336
Mailing Address - Country:US
Mailing Address - Phone:909-429-2864
Mailing Address - Fax:909-429-2868
Practice Address - Street 1:16465 SIERRA LAKES PARKWAY
Practice Address - Street 2:#300
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336
Practice Address - Country:US
Practice Address - Phone:909-429-2864
Practice Address - Fax:909-429-2868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-29
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME858582207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ02404ZMedicare PIN