1144597006 NPI number — MRS. MARY ELLEN WIESENFARTH SIMONE

Table of content: MRS. MARY ELLEN WIESENFARTH SIMONE (NPI 1144597006)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144597006 NPI number — MRS. MARY ELLEN WIESENFARTH SIMONE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WIESENFARTH SIMONE
Provider First Name:
MARY
Provider Middle Name:
ELLEN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SIMONE
Provider Other First Name:
MARY
Provider Other Middle Name:
ELLEN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
D.C.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1144597006
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/21/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
275 W SAN BERNARDINO RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COVINA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91723-1516
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-967-3553
Provider Business Mailing Address Fax Number:
626-967-1523

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
275 W SAN BERNARDINO RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COVINA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91723-1516
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-967-3553
Provider Business Practice Location Address Fax Number:
626-967-1523
Provider Enumeration Date:
11/21/2011

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: 111N00000X , with the licence number:  DC22891 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111NX0100X , with the licence number: DC22891 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111NI0013X , with the licence number: DC22891 , 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: DC22891 . This is a "LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".