1487642336 NPI number — DEL RIO SANITARIUM, 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 1487642336 NPI number — DEL RIO SANITARIUM, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEL RIO SANITARIUM, 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:
DEL RIO GARDENS CARE CENTER, DEL RIO SANITARIUM
Provider Other Organization Name Type Code:
3
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:
1487642336
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/08/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7004 E GAGE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELL GARDENS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90201-2014
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
562-927-6586
Provider Business Mailing Address Fax Number:
562-928-5097

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7004 E GAGE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BELL GARDENS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90201-2014
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-927-6586
Provider Business Practice Location Address Fax Number:
562-928-5097
Provider Enumeration Date:
10/13/2005

Additional Information

Authorized Official

Authorized Official Last Name:
VILLALUZ
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
562-927-6586

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  940000053 , 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: ZZT18080I , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 206190235 . This is a "OSHPD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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