Provider Demographics
NPI:1912111543
Name:LINCOLN HEIGHTS FAMILY & INDUSTRIAL MEDICAL CLINIC
Entity Type:Organization
Organization Name:LINCOLN HEIGHTS FAMILY & INDUSTRIAL MEDICAL CLINIC
Other - Org Name:SUNRISE MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:KWOK-KUEN
Authorized Official - Last Name:CHUNG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-988-2555
Mailing Address - Street 1:437 N. EUCLID AVE.
Mailing Address - Street 2:SUITE A
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91762
Mailing Address - Country:US
Mailing Address - Phone:909-988-2555
Mailing Address - Fax:909-988-4447
Practice Address - Street 1:437 N EUCLID AVE
Practice Address - Street 2:SUITE A
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91762-3456
Practice Address - Country:US
Practice Address - Phone:909-988-2555
Practice Address - Fax:909-988-4447
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6725207Q00000X
CAA37294207VX0000X
CAA33894208D00000X
CAPA 16663363A00000X
CAPA 14845363A00000X
RN 548298363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Multi-Specialty
Not Answered208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Not Answered363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Not Answered363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0056502Medicaid
CAW10710Medicare ID - Type UnspecifiedMEDICARE