Provider Demographics
NPI:1790730786
Name:CHINO MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:CHINO MEDICAL GROUP, INC
Other - Org Name:MY FAMILY MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE ALEX
Authorized Official - Middle Name:
Authorized Official - Last Name:LIRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-591-6446
Mailing Address - Street 1:5475 WALNUT AVE
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-2609
Mailing Address - Country:US
Mailing Address - Phone:909-591-6446
Mailing Address - Fax:909-591-1309
Practice Address - Street 1:5475 WALNUT AVE
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-2609
Practice Address - Country:US
Practice Address - Phone:909-591-6446
Practice Address - Fax:909-591-1309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0059290Medicaid
CAZZZ14251ZMedicare ID - Type Unspecified