1205127693 NPI number — PAN AMERICAN MOA FOUNDATION INC

Table of content: (NPI 1205127693)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205127693 NPI number — PAN AMERICAN MOA FOUNDATION INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAN AMERICAN MOA FOUNDATION INC
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:
MOA WELLNESS CENTER
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:
1205127693
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4533 S. CENTINELA AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90066-6249
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-574-9900
Provider Business Mailing Address Fax Number:
310-574-9901

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4533 S. CENTINELA AVENUE
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:
90066-6249
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-574-9900
Provider Business Practice Location Address Fax Number:
310-574-9901
Provider Enumeration Date:
04/20/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KATO
Authorized Official First Name:
RON
Authorized Official Middle Name:
C
Authorized Official Title or Position:
DIRECTOR/PRESIDENT
Authorized Official Telephone Number:
310-574-9900

Provider Taxonomy Codes

  • Taxonomy code: 2083P0901X , with the licence number:  0002405889-0001-1 , 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)