Provider Demographics
NPI:1114717105
Name:CONCHA, LUIS
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:
Last Name:CONCHA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 W NEVADA ST
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91762-4207
Mailing Address - Country:US
Mailing Address - Phone:909-456-0189
Mailing Address - Fax:
Practice Address - Street 1:360 E 7TH ST STE D
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-6701
Practice Address - Country:US
Practice Address - Phone:909-920-9193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-12
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95360417163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine