1275878159 NPI number — DAISY C DEJESUS

Table of content: DAISY C DEJESUS (NPI 1275878159)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275878159 NPI number — DAISY C DEJESUS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEJESUS
Provider First Name:
DAISY
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SANCHEZ
Provider Other First Name:
DAISY
Provider Other Middle Name:
CONDE
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:
1275878159
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/19/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15305 RAYEN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH HILLS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91343-5117
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-388-0093
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
43520 DIVISION ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LANCASTER
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93535-4089
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-388-0093
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/04/2012

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: 106H00000X , with the licence number:  IMF87559 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 106H00000X , with the licence number: LMFT109995 , 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: 95-2633765 . This is a "MEDI-CAL" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".