1770759516 NPI number — MR. JUSTIN HENRY MOONEY

Table of content: MR. JUSTIN HENRY MOONEY (NPI 1770759516)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770759516 NPI number — MR. JUSTIN HENRY MOONEY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOONEY
Provider First Name:
JUSTIN
Provider Middle Name:
HENRY
Provider Name Prefix Text:
MR.
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:
MOONEY
Provider Other First Name:
JAKE
Provider Other Middle Name:
HENRY
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1770759516
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/01/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1053 N D ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN BERNARDINO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92410-3521
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-886-1691
Provider Business Mailing Address Fax Number:
909-881-8694

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
555 N PERRIS BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PERRIS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92571-2811
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-886-1691
Provider Business Practice Location Address Fax Number:
909-881-8694
Provider Enumeration Date:
05/01/2008

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: 101YM0800X , 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)