Provider Demographics
NPI:1962659573
Name:ULTIMATE MEDICAL PRACTICE A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:ULTIMATE MEDICAL PRACTICE A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:KANGAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-864-1006
Mailing Address - Street 1:3654 HIGHLAND AVE
Mailing Address - Street 2:SUITE 15
Mailing Address - City:HIGHLAND
Mailing Address - State:CA
Mailing Address - Zip Code:92346-2614
Mailing Address - Country:US
Mailing Address - Phone:909-864-1006
Mailing Address - Fax:909-864-1625
Practice Address - Street 1:3654 HIGHLAND AVE
Practice Address - Street 2:SUITE 15
Practice Address - City:HIGHLAND
Practice Address - State:CA
Practice Address - Zip Code:92346-2614
Practice Address - Country:US
Practice Address - Phone:909-864-1006
Practice Address - Fax:909-864-1625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-26
Last Update Date:2009-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA55122261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care