Provider Demographics
NPI:1942482021
Name:REDLANDS FAMILY PRACTICE MEDICAL GROUP INC.
Entity Type:Organization
Organization Name:REDLANDS FAMILY PRACTICE MEDICAL GROUP INC.
Other - Org Name:OPTUM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-793-3208
Mailing Address - Street 1:1520 BARTON RD
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-5467
Mailing Address - Country:US
Mailing Address - Phone:909-793-3208
Mailing Address - Fax:
Practice Address - Street 1:1520 BARTON RD
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-5467
Practice Address - Country:US
Practice Address - Phone:909-793-3208
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:REDLANDS FAMILY PRACTICE MEDICAL GROUP INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-30
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty