1356359673 NPI number — RIALTO MEDICAL SUPPLIES, INC.

Table of content: (NPI 1356359673)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356359673 NPI number — RIALTO MEDICAL SUPPLIES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RIALTO MEDICAL SUPPLIES, 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:
1356359673
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/27/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 583
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE ARROWHEAD
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92352-0583
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-744-8067
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
26598 PINE AVE.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIMFOREST
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92378
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-744-8067
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
COOPER
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
ALAN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
909-744-8067

Provider Taxonomy Codes

  • Taxonomy code: 332BX2000X , with the licence number:  101217 , 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: ZZZ77264Z , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com