Provider Demographics
NPI:1104127109
Name:CLINICA DEL PUEBLO MEDICAL GROUP CORP
Entity type:Organization
Organization Name:CLINICA DEL PUEBLO MEDICAL GROUP CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SAM
Authorized Official - Middle Name:N
Authorized Official - Last Name:RATNAYAKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:661-377-3777
Mailing Address - Street 1:10200 MAIN ST STE B
Mailing Address - Street 2:
Mailing Address - City:LAMONT
Mailing Address - State:CA
Mailing Address - Zip Code:93241-1700
Mailing Address - Country:US
Mailing Address - Phone:661-845-1788
Mailing Address - Fax:661-845-1791
Practice Address - Street 1:10200 MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:LAMONT
Practice Address - State:CA
Practice Address - Zip Code:93241-1700
Practice Address - Country:US
Practice Address - Phone:661-845-1788
Practice Address - Fax:661-845-1791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-06
Last Update Date:2010-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA056363207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty