NPIMap

Organization Active NPI

Cucamonga Valley Medical Group, Inc.

  • Family Medicine Physician
  • Fontana, CA
National Provider Identifier
1497783229
Registry record updated Apr 29, 2013
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
858582 Issued in ME
Legal business name
CUCAMONGA VALLEY MEDICAL GROUP, INC.
Practice address
16465 Sierra Lakes Parkway
#300
Fontana, CA 92336
Phone
(909) 429-2864
Fax
(909) 429-2868
NPI assigned
Jun 29, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 29, 2013

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Kyle Nelson Smart, D.O.NPI 1821030057
Title
President
Phone
(909) 429-2864

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207Q00000X 858582 ME Primary

Addresses

Primary practice location

16465 Sierra Lakes Parkway
#300
Fontana, CA 92336

Mailing address

16465 Sierra Lakes Parkway
#300
Fontana, CA 92336
Phone (909) 429-2864

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20060712000099 CA Part B Supplier - Clinic/Group Practice 6709899883 Receives reassigned benefits from 25 practitioners
Practice locations: Eastvale, CA; Fontana, CA; Rancho Cucamonga, CA; Upland, CA

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
05D1051702Cucamonga Valley Medical Group Inc16465 Sierra Lakes Pkwy Ste 300, Fontana, CA 92336Provider-performed microscopyMar 7, 2026

National Provider Directory

National Provider Directory

Locations

11901 Business Blvd
Ste 209
Eagle River, AK 99577
Phone (907) 694-6002

16839 Ramona Ave
Ste 401
Fontana, CA 92336
Phone (909) 429-2864

7777 Milliken Ave
#9173
Rancho Cucamonga, CA 91730

Networks

  • BSC 65 PLUS INDIVIDUAL MAPDPlans: Blue Shield 65 Plus (HMO) (H0504-015-000, H0504); Blue Shield 65 Plus (HMO) (H0504-039-000, H0504); Blue Shield 65 Plus Plan 2 (HMO) (H0504-021-000, H0504); Blue Shield Inspire (HMO) (H0504-041-000, H0504); Blue Shield 65 Plus (HMO) (H0504-038-000, H0504); Blue Shield Inspire (HMO) (H0504-047-000, H0504); Blue Shield 65 Plus (HMO) (H0504-026-000, H0504); Blue Shield Advantage (HMO) (H0504-050-000, H0504); Blue Shield AdvantageOptimum Plan (HMO) (H5928-004-000, H5928); Blue Shield Inspire (HMO) (H0504-043-000, H0504)…

Practitioners & affiliated clinicians

Practitioners 30

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 30

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1151539200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1367193600000",
    "number": "1497783229",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "16465 SIERRA LAKES PARKWAY",
            "address_2": "#300",
            "city": "FONTANA",
            "state": "CA",
            "postal_code": "92336",
            "telephone_number": "909-429-2864",
            "fax_number": "909-429-2868"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "16465 SIERRA LAKES PARKWAY",
            "address_2": "#300",
            "city": "FONTANA",
            "state": "CA",
            "postal_code": "92336",
            "telephone_number": "909-429-2864",
            "fax_number": "909-429-2868"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CUCAMONGA VALLEY MEDICAL GROUP, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-06-29",
        "last_updated": "2013-04-29",
        "status": "A",
        "authorized_official_last_name": "SMART",
        "authorized_official_first_name": "KYLE",
        "authorized_official_middle_name": "NELSON",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "909-429-2864",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "D.O."
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine",
            "state": "ME",
            "license": "858582",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Fontana, CA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 29, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.