Provider Demographics
NPI:1982787206
Name:LINCOLN HEIGHTS FAMILY AND INDUSTRIAL MEDICAL CLINIC
Entity type:Organization
Organization Name:LINCOLN HEIGHTS FAMILY AND INDUSTRIAL MEDICAL CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:KWOK-KUEN
Authorized Official - Last Name:CHUNG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-623-3600
Mailing Address - Street 1:1501 E HOLT AVE
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-5823
Mailing Address - Country:US
Mailing Address - Phone:909-623-3600
Mailing Address - Fax:909-623-3383
Practice Address - Street 1:1501 E HOLT AVE
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-5823
Practice Address - Country:US
Practice Address - Phone:909-623-3600
Practice Address - Fax:909-623-3383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA37294207V00000X
CAA50856208000000X
CAA33894208D00000X
CAPA 14845363A00000X
CAPA 16663363A00000X
CAPA 17061363A00000X
CARN 548298363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Not Answered208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Not Answered363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Not Answered363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPA16663AOtherPETER LE PPIN
CAGR0056501Medicaid
CAWPA16663AOtherPETER LE PPIN
CAA27288Medicare UPIN
CAGR0056501Medicaid