1053444935 NPI number — PROHEALTH PARTNERS, A MEDICAL GROUP, INC.

Table of content: (NPI 1053444935)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053444935 NPI number — PROHEALTH PARTNERS, A MEDICAL GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROHEALTH PARTNERS, A MEDICAL GROUP, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053444935
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/25/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1045 ATLANTIC AVE
Provider Second Line Business Mailing Address:
SUITE 705
Provider Business Mailing Address City Name:
LONG BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90813-3408
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3650 SOUTH ST
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
LAKEWOOD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90712-1502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-630-0910
Provider Business Practice Location Address Fax Number:
562-630-4877
Provider Enumeration Date:
03/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LUGLIANI
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
562-491-9281

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: GR006415Y , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZ00491Z . This is a "BLUE SHIELD GROUP NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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