1336316504 NPI number — PROF. AMI CHIRSTINE TEODORO MLP-PA

Table of content: PROF. AMI CHIRSTINE TEODORO MLP-PA (NPI 1336316504)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336316504 NPI number — PROF. AMI CHIRSTINE TEODORO MLP-PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TEODORO
Provider First Name:
AMI
Provider Middle Name:
CHIRSTINE
Provider Name Prefix Text:
PROF.
Provider Name Suffix Text:
Provider Credential Text:
MLP-PA
Provider Gender Code:
F

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:
1336316504
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/11/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 UNIVERSITY AVE STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SACRAMENTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95825-6527
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-437-0570
Provider Business Mailing Address Fax Number:
916-437-0470

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
747 52ND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OAKLAND
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94609-1809
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-428-3238
Provider Business Practice Location Address Fax Number:
510-601-3904
Provider Enumeration Date:
05/15/2008

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: 363AM0700X , with the licence number:  PA19708 , 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: PA19708 . This is a "PAC LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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