1013046705 NPI number — SOFT TISSUE MEDICAL CENTER INC

Table of content: (NPI 1013046705)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013046705 NPI number — SOFT TISSUE MEDICAL CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOFT TISSUE MEDICAL CENTER INC
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:
1013046705
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/28/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
648 PINE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PACIFIC GROVE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93950-3347
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
831-373-0188
Provider Business Mailing Address Fax Number:
831-373-6979

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
648 PINE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PACIFIC GROVE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93950-3347
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
831-373-0188
Provider Business Practice Location Address Fax Number:
831-373-6979
Provider Enumeration Date:
03/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PAYAN
Authorized Official First Name:
ANTHONY
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
OWNER/OFFICER
Authorized Official Telephone Number:
831-373-0188

Provider Taxonomy Codes

  • Taxonomy code: 111NR0400X , with the licence number:  DC19245 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208100000X , with the licence number: G42005 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: DC0192450 . This is a "DAP - BS" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 00G420050 . This is a "RWT - BS" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1619998960 . This is a "RWT NPI" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: DC19245 . This is a "DAP - BC" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: G42005 . This is a "RWT - BC" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ66746Z . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1134258825 . This is a "DAP - NPI" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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