Provider Demographics
NPI:1851007173
Name:OG MOBILE MEDICAL GROUP
Entity Type:Organization
Organization Name:OG MOBILE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK-POVEDA
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:909-274-9143
Mailing Address - Street 1:PO BOX 8896
Mailing Address - Street 2:
Mailing Address - City:ALTA LOMA
Mailing Address - State:CA
Mailing Address - Zip Code:91701-0896
Mailing Address - Country:US
Mailing Address - Phone:909-274-9143
Mailing Address - Fax:909-295-5911
Practice Address - Street 1:8972 APPALOOSA CT
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91737-1401
Practice Address - Country:US
Practice Address - Phone:909-274-9143
Practice Address - Fax:909-294-5911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-30
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty