1457597411 NPI number — T K LOAN PHAM MD INC

Table of content: (NPI 1457597411)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457597411 NPI number — T K LOAN PHAM MD INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
T K LOAN PHAM MD 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:
1457597411
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/01/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 13550
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALM DESERT
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92255-3550
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-771-2626
Provider Business Mailing Address Fax Number:
760-771-2620

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
79440 CORPORATE CENTRE DR.
Provider Second Line Business Practice Location Address:
STE 117
Provider Business Practice Location Address City Name:
LA QUINTA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92253-7241
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-771-2626
Provider Business Practice Location Address Fax Number:
760-771-2620
Provider Enumeration Date:
12/22/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PHAM
Authorized Official First Name:
THI
Authorized Official Middle Name:
KIM LOAN
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
760-771-2626

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  A60749 , 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)