1043456742 NPI number — CALIFORNIA NEUROMEDICAL SERVICES

Table of content: (NPI 1043456742)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043456742 NPI number — CALIFORNIA NEUROMEDICAL SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CALIFORNIA NEUROMEDICAL SERVICES
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:
1043456742
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/22/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
511 BROOKSIDE AVE
Provider Second Line Business Mailing Address:
STE. 102
Provider Business Mailing Address City Name:
REDLANDS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92373-4611
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-557-8727
Provider Business Mailing Address Fax Number:
909-335-8514

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
301 N PRAIRIE AVE
Provider Second Line Business Practice Location Address:
STE.315
Provider Business Practice Location Address City Name:
INGLEWOOD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90301-4507
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-680-0304
Provider Business Practice Location Address Fax Number:
310-680-0305
Provider Enumeration Date:
12/30/2008

Additional Information

Authorized Official

Authorized Official Last Name:
YOUNG
Authorized Official First Name:
ROSABEL
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
310-428-2244

Provider Taxonomy Codes

  • Taxonomy code: 2084N0600X , with the licence number:  G64157 , 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: 180519600 . This is a "OWCP" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 000G641570 . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 00G641570 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: RR1022 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: P00011946 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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