1013218130 NPI number — JANETTE JOYCE MARY COPPOTELLI DPT

Table of content: JANETTE JOYCE MARY COPPOTELLI DPT (NPI 1013218130)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013218130 NPI number — JANETTE JOYCE MARY COPPOTELLI DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COPPOTELLI
Provider First Name:
JANETTE
Provider Middle Name:
JOYCE MARY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GLINKA
Provider Other First Name:
JANETTE
Provider Other Middle Name:
JOYCE MARY
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1013218130
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/14/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24630 WASHINGTON AVE
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
MURRIETA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92562-6177
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-696-9353
Provider Business Mailing Address Fax Number:
951-973-7216

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17270 BEAR VALLEY RD
Provider Second Line Business Practice Location Address:
SUITE E-105
Provider Business Practice Location Address City Name:
VICTORVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92395-7751
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-955-6061
Provider Business Practice Location Address Fax Number:
760-955-6062
Provider Enumeration Date:
11/04/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT 35545 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0PT355450 . This is a "BLUE SHIELD PIN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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