1457469884 NPI number — LA VERNE FAMILY MEDICAL CENTER INC

Table of content: (NPI 1457469884)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457469884 NPI number — LA VERNE FAMILY MEDICAL CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LA VERNE FAMILY MEDICAL CENTER 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:
1457469884
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/09/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2100 FOOTHILL BLVD
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
LA VERNE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91750-2905
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-596-1941
Provider Business Mailing Address Fax Number:
909-596-1943

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2100 FOOTHILL BLVD
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
LA VERNE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91750-2905
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-596-1941
Provider Business Practice Location Address Fax Number:
909-596-1943
Provider Enumeration Date:
08/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WONG
Authorized Official First Name:
TAN
Authorized Official Middle Name:
LIN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
909-596-1941

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  A50496 , 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: W20443 . This is a "MEDICARE GROUP ID" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com