Provider Demographics
NPI:1770725939
Name:JARCO MEDICAL GROUP, LLC
Entity type:Organization
Organization Name:JARCO MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JECONIAS
Authorized Official - Middle Name:LOPEZ
Authorized Official - Last Name:DEMIAR
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA, RN, NA
Authorized Official - Phone:909-222-4779
Mailing Address - Street 1:PO BOX M
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-0556
Mailing Address - Country:US
Mailing Address - Phone:909-222-4779
Mailing Address - Fax:909-222-4779
Practice Address - Street 1:12030 LA CADENA DR
Practice Address - Street 2:
Practice Address - City:GRAND TERRACE
Practice Address - State:CA
Practice Address - Zip Code:92313-3613
Practice Address - Country:US
Practice Address - Phone:909-222-4779
Practice Address - Fax:909-222-4779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-01
Last Update Date:2010-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN160039261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABU467BMedicare PIN
ZZZ23065ZMedicare PIN
CABU467AMedicare PIN