1649745282 NPI number — JESUS EFREN VITAL

Table of content: JESUS EFREN VITAL (NPI 1649745282)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649745282 NPI number — JESUS EFREN VITAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VITAL
Provider First Name:
JESUS
Provider Middle Name:
EFREN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

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:
1649745282
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/10/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9140 VAN NUYS BLVD STE 211
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PANORAMA CITY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91402-6764
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-895-2206
Provider Business Mailing Address Fax Number:
818-895-0824

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9140 VAN NUYS BLVD STE 211
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PANORAMA CITY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91402-6764
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-895-2206
Provider Business Practice Location Address Fax Number:
818-895-0824
Provider Enumeration Date:
10/10/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  5565 , 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)