Provider Demographics
NPI:1962688127
Name:COLTON VALLEY MEDICAL CARE INC
Entity Type:Organization
Organization Name:COLTON VALLEY MEDICAL CARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HARRY
Authorized Official - Middle Name:RAYMOND
Authorized Official - Last Name:WEBB
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:909-825-3202
Mailing Address - Street 1:502 W VALLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-2249
Mailing Address - Country:US
Mailing Address - Phone:909-825-3202
Mailing Address - Fax:909-825-9375
Practice Address - Street 1:502 W VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-2249
Practice Address - Country:US
Practice Address - Phone:909-825-3202
Practice Address - Fax:909-825-9375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-17
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA23744207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A237440Medicaid
CA00A237440Medicare PIN