Provider Demographics
NPI:1740448786
Name:SOUTHLAND SAN GABRIEL VALLEY MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:SOUTHLAND SAN GABRIEL VALLEY MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:TH
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:626-782-6202
Mailing Address - Street 1:820 S GARFIELD AVE
Mailing Address - Street 2:SUITE 201 A
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91801-5838
Mailing Address - Country:US
Mailing Address - Phone:626-782-6202
Mailing Address - Fax:626-249-5399
Practice Address - Street 1:820 S GARFIELD AVE
Practice Address - Street 2:SUITE 201 A
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91801-5838
Practice Address - Country:US
Practice Address - Phone:626-782-6202
Practice Address - Fax:626-249-5399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-27
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization