Basic Information
| Provider Information | |||||||||
| NPI: | 1639109713 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VIA VERDE MEDICAL GROUP, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1125 VIA VERDE | ||||||||
| Address2: | |||||||||
| City: | SAN DIMAS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917734400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095929778 | ||||||||
| FaxNumber: | 9095996126 | ||||||||
| Practice Location | |||||||||
| Address1: | 1125 VIA VERDE | ||||||||
| Address2: | |||||||||
| City: | SAN DIMAS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917734400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095929778 | ||||||||
| FaxNumber: | 9095996126 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2006 | ||||||||
| LastUpdateDate: | 02/19/2013 | ||||||||
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| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9095929778 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 20A5217 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.