Provider Demographics
NPI:1962518126
Name:SOUTHERN ONTARIO MEDICAL CENTER
Entity type:Organization
Organization Name:SOUTHERN ONTARIO MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:YUAN
Authorized Official - Last Name:HO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-986-2288
Mailing Address - Street 1:2525 S EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91762-6620
Mailing Address - Country:US
Mailing Address - Phone:909-986-2288
Mailing Address - Fax:909-986-1892
Practice Address - Street 1:2525 S EUCLID AVE
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91762-6620
Practice Address - Country:US
Practice Address - Phone:909-986-2288
Practice Address - Fax:909-986-1892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2009-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA31364207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0010140Medicaid