1164627436 NPI number — AUDRA PONCI BADO M.P.T.

Table of content: AUDRA PONCI BADO M.P.T. (NPI 1164627436)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164627436 NPI number — AUDRA PONCI BADO M.P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BADO
Provider First Name:
AUDRA
Provider Middle Name:
PONCI
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.P.T.
Provider Gender Code:
F

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:
1164627436
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12099 W. WASHINGTON BLVD
Provider Second Line Business Mailing Address:
STE 300
Provider Business Mailing Address City Name:
CULVER CITE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90066
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
213-935-8566
Provider Business Mailing Address Fax Number:
310-535-0009

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12099 W WASHINGTON BLVD STE 300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90066-2621
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-935-8566
Provider Business Practice Location Address Fax Number:
310-535-0009
Provider Enumeration Date:
06/18/2007

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:  26768 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2251H1200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2251H1200X , with the licence number: 26768 , 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)