Provider Demographics
NPI:1952590523
Name:ACEVEDO MEDICAL GROUP, A MEDICAL CORPORATION
Entity type:Organization
Organization Name:ACEVEDO MEDICAL GROUP, A MEDICAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LORETO
Authorized Official - Middle Name:M
Authorized Official - Last Name:ACEVEDO-CARMONA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-622-2345
Mailing Address - Street 1:1818 N ORANGE GROVE AVE
Mailing Address - Street 2:STE 305
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-3028
Mailing Address - Country:US
Mailing Address - Phone:909-622-2345
Mailing Address - Fax:909-397-7654
Practice Address - Street 1:1818 N ORANGE GROVE AVE
Practice Address - Street 2:STE 305
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-3028
Practice Address - Country:US
Practice Address - Phone:909-622-2345
Practice Address - Fax:909-397-7654
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-19
Last Update Date:2009-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA74961207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH39175Medicare UPIN
CAW21953Medicare PIN