1225579006 NPI number — LG AGUILAR TABORA, MD INC

Table of content: (NPI 1225579006)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225579006 NPI number — LG AGUILAR TABORA, MD INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LG AGUILAR TABORA, MD 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:
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:
1225579006
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/28/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 928684
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92192-8684
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-252-8655
Provider Business Mailing Address Fax Number:
619-930-9022

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8650 GENESSEE AVE. STE 214
Provider Second Line Business Practice Location Address:
#8684
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92192-8684
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-252-8655
Provider Business Practice Location Address Fax Number:
619-930-9022
Provider Enumeration Date:
03/14/2017

Additional Information

Authorized Official

Authorized Official Last Name:
AGUILAR TABORA
Authorized Official First Name:
LESLY
Authorized Official Middle Name:
GISELLE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
858-252-8655

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X , with the licence number:  A106980 , 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: PENDING . This is a "PENDING MEDICARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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