1073534608 NPI number — SAN GABRIEL HEALTH CLINIC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073534608 NPI number — SAN GABRIEL HEALTH CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAN GABRIEL HEALTH CLINIC
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:
1073534608
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2630 SAN GABRIEL BLVD
Provider Second Line Business Mailing Address:
SUITE 105
Provider Business Mailing Address City Name:
ROSEMEAD
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91770-5204
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-288-2007
Provider Business Mailing Address Fax Number:
626-288-2116

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2630 SAN GABRIEL BLVD
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
ROSEMEAD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91770-5204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-288-2007
Provider Business Practice Location Address Fax Number:
626-288-2116
Provider Enumeration Date:
07/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HUYNH
Authorized Official First Name:
BO
Authorized Official Middle Name:
TAN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
626-288-2007

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  FNP34454 , 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: FNP34454 . This is a "FICTITIOUS BUSINESS #" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0102390 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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