1609058445 NPI number — DACOSTA COLLYMORE

Table of content: (NPI 1609058445)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609058445 NPI number — DACOSTA COLLYMORE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DACOSTA COLLYMORE
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:
PACIFIC REHABILITATION
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:
1609058445
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/24/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5000 OVERLAND AVE
Provider Second Line Business Mailing Address:
#4
Provider Business Mailing Address City Name:
CULVER CITY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90230
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-836-7650
Provider Business Mailing Address Fax Number:
310-836-7651

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5000 OVERLAND AVE
Provider Second Line Business Practice Location Address:
#4
Provider Business Practice Location Address City Name:
CULVER CITY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90230
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-836-7650
Provider Business Practice Location Address Fax Number:
310-836-7651
Provider Enumeration Date:
12/04/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
COLLYMORE
Authorized Official First Name:
DACOSTA
Authorized Official Middle Name:
ALONZO
Authorized Official Title or Position:
CEO OWNER
Authorized Official Telephone Number:
310-836-7650

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  20709 , 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)