1245424308 NPI number — FIRST CHOICE DOCTORS MEDICAL GROUP

Table of content: (NPI 1245424308)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245424308 NPI number — FIRST CHOICE DOCTORS MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FIRST CHOICE DOCTORS MEDICAL GROUP
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:
1245424308
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/31/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13029A VICTORY BLVD # 525
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH HOLLYWOOD
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91606-2925
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-759-2555
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6801 COLDWATER CANYON AVE STE 1E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH HOLLYWOOD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91605-5167
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-759-2555
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/31/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MISSIRIAN
Authorized Official First Name:
ROBERE
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
818-759-2555

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  G84264 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207XS0117X , with the licence number: G84264 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QA1903X , with the licence number: G84264 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)