1952412793 NPI number — BRIAN FLEMING

Table of content: BRIAN FLEMING (NPI 1952412793)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952412793 NPI number — BRIAN FLEMING

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FLEMING
Provider First Name:
BRIAN
Provider Middle Name:
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:
1952412793
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/12/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1501 RAMONA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH PASADENA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91030-3734
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-622-0384
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3535 W IMPERIAL HWY STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INGLEWOOD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90303-6204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-622-0384
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/31/2006

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: 213EP1101X , with the licence number:  E-3666 , 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: 000E36661 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000E36662 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000E36663 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000E36660 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".