1174662233 NPI number — JIMMY MAK LAC PHD

Table of content: JIMMY MAK LAC PHD (NPI 1174662233)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174662233 NPI number — JIMMY MAK LAC PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAK
Provider First Name:
JIMMY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LAC PHD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MAI
Provider Other First Name:
JIMIN
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1174662233
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1777 BELLFLOWER BLVD
Provider Second Line Business Mailing Address:
# 114
Provider Business Mailing Address City Name:
LONG BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90815
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
562-986-7922
Provider Business Mailing Address Fax Number:
562-494-8993

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1777 BELLFLOWER BLVD
Provider Second Line Business Practice Location Address:
# 114
Provider Business Practice Location Address City Name:
LONG BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90815
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-986-7922
Provider Business Practice Location Address Fax Number:
562-494-8993
Provider Enumeration Date:
02/05/2007

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: 171100000X , with the licence number:  AC 4144 , 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: AC0041440 . This is a "MEDICAL" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".