1053782441 NPI number — MBM PLUS PROFESSIONAL CORPORATION

Table of content: (NPI 1053782441)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053782441 NPI number — MBM PLUS PROFESSIONAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MBM PLUS PROFESSIONAL CORPORATION
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:
1053782441
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/27/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8252 SETTLERS INN CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89178-4872
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-378-9549
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8252 SETTLERS INN CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89178-4872
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-378-9549
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/12/2015

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MELNIC
Authorized Official First Name:
NATALYA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
818-378-9549

Provider Taxonomy Codes

  • Taxonomy code: 171W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 291U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 05D2044828 . This is a "CLIA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 572011 . This is a "BCBSF" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".