1861425696 NPI number — NEIL R VINCENT

Table of content: NEIL R VINCENT (NPI 1861425696)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861425696 NPI number — NEIL R VINCENT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VINCENT
Provider First Name:
NEIL
Provider Middle Name:
R
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:
1861425696
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
54701 FILE NUMBER
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90074-4701
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-558-3111
Provider Business Mailing Address Fax Number:
909-558-3905

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11406 LOMA LINDA DR
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
LOMA LINDA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92354-3711
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-558-6277
Provider Business Practice Location Address Fax Number:
909-558-3905
Provider Enumeration Date:
07/07/2006

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: 171100000X , with the licence number:  AC7124 , 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)

  • Identifier: AC0071240 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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