Provider Demographics
NPI:1881811404
Name:FOOTHILL COMMUNITY MEDICAL CORP.
Entity type:Organization
Organization Name:FOOTHILL COMMUNITY MEDICAL CORP.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAFAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:CARCAMO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-858-5199
Mailing Address - Street 1:647 E ARROW HWY
Mailing Address - Street 2:
Mailing Address - City:AZUSA
Mailing Address - State:CA
Mailing Address - Zip Code:91702-5802
Mailing Address - Country:US
Mailing Address - Phone:626-858-5199
Mailing Address - Fax:626-858-5299
Practice Address - Street 1:647 E ARROW HWY
Practice Address - Street 2:
Practice Address - City:AZUSA
Practice Address - State:CA
Practice Address - Zip Code:91702-5802
Practice Address - Country:US
Practice Address - Phone:626-858-5199
Practice Address - Fax:626-858-5299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA66675207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0090650Medicaid
CAGR0090560Medicaid