1568543783 NPI number — CARLSON, HANSEN, KWON-HONG, MDS

Table of content: (NPI 1568543783)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568543783 NPI number — CARLSON, HANSEN, KWON-HONG, MDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CARLSON, HANSEN, KWON-HONG, MDS
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:
1568543783
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5101 MESA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAKDALE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95361-7858
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-848-8903
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1213 COFFEE RD
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
MODESTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95355-4229
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-549-9900
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CARLSON
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
M
Authorized Official Title or Position:
MANAGING PARTNER
Authorized Official Telephone Number:
209-549-9900

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  G27090 , 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)





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