Provider Demographics
NPI:1053788471
Name:LA GUADALUPANA MEDICAL GROUP A MEDICAL CORPORATION
Entity type:Organization
Organization Name:LA GUADALUPANA MEDICAL GROUP A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ARAM
Authorized Official - Middle Name:
Authorized Official - Last Name:BONNI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-839-8676
Mailing Address - Street 1:307 E 1ST ST
Mailing Address - Street 2:1C
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92701-5302
Mailing Address - Country:US
Mailing Address - Phone:714-839-8676
Mailing Address - Fax:714-839-8675
Practice Address - Street 1:307 E 1ST ST
Practice Address - Street 2:1C
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-5302
Practice Address - Country:US
Practice Address - Phone:714-839-8676
Practice Address - Fax:714-839-8675
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UROGYNECOLOGY ASSOCIATES A MEDICAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-09-02
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA66385146N00000X, 261QA0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, BasicGroup - Multi-Specialty
No261QA0005XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Family Planning FacilityGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA11404859164Medicaid
CAA66385OtherCALIFORNIA MEDICAL LICENSE
CAA66385OtherCALIFORNIA MEDICAL LICENSE
CA11404859164Medicaid