1497939193 NPI number — LOS ANGELES COUNTY - WIDNEY MTU

Table of content: (NPI 1497939193)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497939193 NPI number — LOS ANGELES COUNTY - WIDNEY MTU

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LOS ANGELES COUNTY - WIDNEY MTU
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:
1497939193
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/18/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9320 TELSTAR AVE STE 226
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EL MONTE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91731-2816
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-288-4584
Provider Business Mailing Address Fax Number:
626-569-6480

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2302 S GRAMERCY PL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90018-1323
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-731-8442
Provider Business Practice Location Address Fax Number:
323-733-2486
Provider Enumeration Date:
12/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FORD
Authorized Official First Name:
WESLEY
Authorized Official Middle Name:
L
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
626-569-6001

Provider Taxonomy Codes

  • Taxonomy code: 261QR0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: CCS00135F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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