Provider Demographics
NPI:1730112426
Name:PREMIER FAMILY MEDICINE ASSOCIATES, INC
Entity Type:Organization
Organization Name:PREMIER FAMILY MEDICINE ASSOCIATES, INC
Other - Org Name:PVHC AT CHINO HILLS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:LETICIA
Authorized Official - Last Name:VALADEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-630-7875
Mailing Address - Street 1:2140 GRAND AVE STE 125
Mailing Address - Street 2:
Mailing Address - City:CHINO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91709-6802
Mailing Address - Country:US
Mailing Address - Phone:909-630-7875
Mailing Address - Fax:909-469-2107
Practice Address - Street 1:2140 GRAND AVE STE 125
Practice Address - Street 2:
Practice Address - City:CHINO HILLS
Practice Address - State:CA
Practice Address - Zip Code:91709-6802
Practice Address - Country:US
Practice Address - Phone:909-630-7875
Practice Address - Fax:909-630-7876
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PREMIER FAMILY MEDICINE ASSOCIATES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-08
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207Q00000X
CA550000261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1730112426Medicaid
CA05D0977154OtherCLIA #
240000815OtherDHS CERT
ZZZ07684ZOtherBLUE SHIELD OF CALIFORNIA
CAZZZ25560ZOtherMEDICARE GROUP # FOR NO- CAL
CAGR0083731Medicaid
DF6140OtherRAILROAD
CO06 05671OtherCHINO HILLS BUSINESS LICENSE