1306017603 NPI number — MISSION CITY COMMUNITY NETWORK, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306017603 NPI number — MISSION CITY COMMUNITY NETWORK, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MISSION CITY COMMUNITY NETWORK, 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:
1306017603
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/10/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15206 PARTHENIA 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:
91343-5305
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-895-3100
Provider Business Mailing Address Fax Number:
818-892-3352

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9919 LAUREL CANYON BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PACOIMA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91331-3940
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-686-4243
Provider Business Practice Location Address Fax Number:
818-686-4259
Provider Enumeration Date:
03/14/2008

Additional Information

Authorized Official

Authorized Official Last Name:
GUPTA
Authorized Official First Name:
NIK
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
818-895-3100

Provider Taxonomy Codes

  • Taxonomy code: 261QC1500X , with the licence number:  960001450 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QF0400X , with the licence number: 960001450 , 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: FHC70436F . This is a "MEDICAL PROVIDER NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: EAP70436F . This is a "MEDICAL PROVIDER NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: HAP70436F . This is a "MEDICAL PROVIDER NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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