1013155753 NPI number — KIMBERLY ANDREA BRISCO

Table of content: KIMBERLY ANDREA BRISCO (NPI 1013155753)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013155753 NPI number — KIMBERLY ANDREA BRISCO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRISCO
Provider First Name:
KIMBERLY
Provider Middle Name:
ANDREA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

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:
1013155753
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/03/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
645 E 120TH ST
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:
90059-2721
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
323-779-6707
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5436 S BROADWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90037-4126
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-234-6261
Provider Business Practice Location Address Fax Number:
323-234-6265
Provider Enumeration Date:
02/03/2009

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: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 195709A . This is a "MEDICAL" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com