1114090693 NPI number — GEOFFERY ODEGA

Table of content: (NPI 1114090693)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114090693 NPI number — GEOFFERY ODEGA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GEOFFERY ODEGA
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:
JOY MEDICAL SUPPLIES
Provider Other Organization Name Type Code:
3
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:
1114090693
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/19/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1905 E 17TH ST
Provider Second Line Business Mailing Address:
STE 124
Provider Business Mailing Address City Name:
SANTA ANA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92705-8628
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-480-0098
Provider Business Mailing Address Fax Number:
714-480-0081

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1905 E 17TH ST
Provider Second Line Business Practice Location Address:
STE 124
Provider Business Practice Location Address City Name:
SANTA ANA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92705-8628
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-480-0098
Provider Business Practice Location Address Fax Number:
714-480-0081
Provider Enumeration Date:
11/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ODEGA
Authorized Official First Name:
GEOFFERY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
714-480-0098

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  45855 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332BC3200X , with the licence number: 45855 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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