1730400961 NPI number — ELLIOT GROSS A PROF CORP

Table of content: (NPI 1730400961)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730400961 NPI number — ELLIOT GROSS A PROF CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELLIOT GROSS A PROF CORP
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:
1730400961
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/24/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3831 HUGHES AVE
Provider Second Line Business Mailing Address:
509
Provider Business Mailing Address City Name:
CULVER CITY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90232-2751
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-559-4833
Provider Business Mailing Address Fax Number:
310-558-0624

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3831 HUGHES AVE
Provider Second Line Business Practice Location Address:
509
Provider Business Practice Location Address City Name:
CULVER CITY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90232-2751
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-559-4833
Provider Business Practice Location Address Fax Number:
310-558-0624
Provider Enumeration Date:
06/22/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GROSS
Authorized Official First Name:
ELLIOT
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
310-559-4833

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  G28678 , 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)