1730524406 NPI number — CAMELIA C WOGU MD LTD

Table of content: (NPI 1730524406)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730524406 NPI number — CAMELIA C WOGU MD LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CAMELIA C WOGU MD LTD
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:
1730524406
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/02/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3380 LA SIERRA AVE STE 104-613
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIVERSIDE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92503-5271
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-367-5586
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 CANAL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KING CITY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93930-3431
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-453-3799
Provider Business Practice Location Address Fax Number:
702-453-5741
Provider Enumeration Date:
05/07/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LABRECQUE
Authorized Official First Name:
LORI
Authorized Official Middle Name:
Authorized Official Title or Position:
ACCTS MGR
Authorized Official Telephone Number:
702-453-3799

Provider Taxonomy Codes

  • Taxonomy code: 208M00000X , with the licence number:  A102408 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208M00000X , with the licence number: 19686 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 19686 . This is a "MT LIC" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
  • Identifier: A102408 . This is a "CA LIC" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".