Provider Demographics
NPI:1962486993
Name:CHINO PEDIATRIC MEDICAL GROUP
Entity Type:Organization
Organization Name:CHINO PEDIATRIC MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:DARYL
Authorized Official - Middle Name:K
Authorized Official - Last Name:TSAI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-393-6202
Mailing Address - Street 1:15944 LOS SERRANOS COUNTRY CLUB DR
Mailing Address - Street 2:SUITE 220
Mailing Address - City:CHINO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91709-3991
Mailing Address - Country:US
Mailing Address - Phone:909-393-6202
Mailing Address - Fax:909-363-6204
Practice Address - Street 1:15944 LOS SERRANOS COUNTRY CLUB DR
Practice Address - Street 2:SUITE 220
Practice Address - City:CHINO HILLS
Practice Address - State:CA
Practice Address - Zip Code:91709-3991
Practice Address - Country:US
Practice Address - Phone:909-393-6202
Practice Address - Fax:909-393-6204
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-02
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27982208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A674780Medicaid
CA1447235080Medicaid
CA00A673880Medicaid
CA1285619825Medicaid