1063565604 NPI number — BRENT STREET FAMILY PRACTICE

Table of content: (NPI 1063565604)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063565604 NPI number — BRENT STREET FAMILY PRACTICE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRENT STREET FAMILY PRACTICE
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:
1063565604
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
168 N BRENT ST
Provider Second Line Business Mailing Address:
STE 502
Provider Business Mailing Address City Name:
VENTURA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93003-2817
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-641-2000
Provider Business Mailing Address Fax Number:
805-653-1644

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
168 N BRENT ST
Provider Second Line Business Practice Location Address:
STE 502
Provider Business Practice Location Address City Name:
VENTURA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93003-2817
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-641-2000
Provider Business Practice Location Address Fax Number:
805-653-1644
Provider Enumeration Date:
01/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DODGE
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
F
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
805-641-2000

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  G43925 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207Q00000X , with the licence number: G40594 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: G26650 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: G46052 , 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: 00G266500 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00G405940 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00G460520 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00G439250 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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