Provider Demographics
NPI:1497809297
Name:CMG CLINICAL LABORATORY AND ANCILLARY SERVICES, INC.
Entity Type:Organization
Organization Name:CMG CLINICAL LABORATORY AND ANCILLARY SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTRACTS ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ADRIENNE
Authorized Official - Middle Name:M
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-398-1550
Mailing Address - Street 1:840 TOWNE CENTER DR
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-5900
Mailing Address - Country:US
Mailing Address - Phone:909-398-1550
Mailing Address - Fax:
Practice Address - Street 1:1866 N ORANGE GROVE AVE
Practice Address - Street 2:SUITE #101
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-3031
Practice Address - Country:US
Practice Address - Phone:909-622-8451
Practice Address - Fax:909-620-2560
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2023-11-13
Deactivation Date:2023-03-10
Deactivation Code:
Reactivation Date:2023-06-06
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207U00000XAllopathic & Osteopathic PhysiciansNuclear MedicineGroup - Multi-Specialty
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear CardiologyGroup - Multi-Specialty
No207UN0902XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Imaging & TherapyGroup - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Multi-Specialty
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CATP111Medicare PIN