1033413463 NPI number — MRS. RENEE GRINNELL CAPOZZOLA MPT

Table of content: MRS. RENEE GRINNELL CAPOZZOLA MPT (NPI 1033413463)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033413463 NPI number — MRS. RENEE GRINNELL CAPOZZOLA MPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CAPOZZOLA
Provider First Name:
RENEE
Provider Middle Name:
GRINNELL
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MPT
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:
1033413463
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/28/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
714 11TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HERMOSA BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90254-3938
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-210-6374
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 CIVIC PLAZA DR
Provider Second Line Business Practice Location Address:
SUITE # 625
Provider Business Practice Location Address City Name:
CARSON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90745-2243
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-549-4500
Provider Business Practice Location Address Fax Number:
310-549-4700
Provider Enumeration Date:
12/28/2010

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: 225100000X , with the licence number:  22426 , 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)





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