1063858454 NPI number — TEMECULA VALLEY DIGESTIVE DISEASE CONSULTANTS A MEDICAL CORPORATION

Table of content: (NPI 1063858454)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063858454 NPI number — TEMECULA VALLEY DIGESTIVE DISEASE CONSULTANTS A MEDICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TEMECULA VALLEY DIGESTIVE DISEASE CONSULTANTS A MEDICAL 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:
6
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:
1063858454
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/13/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
28078 BAXTER RD
Provider Second Line Business Mailing Address:
SUITE 530
Provider Business Mailing Address City Name:
MURRIETA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92563-1402
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-566-5229
Provider Business Mailing Address Fax Number:
951-566-5554

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
521 E ELDER ST
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
FALLBROOK
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92028-3081
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-566-5229
Provider Business Practice Location Address Fax Number:
951-566-5554
Provider Enumeration Date:
05/13/2013

Additional Information

Authorized Official

Authorized Official Last Name:
HONG
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
951-566-5229

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  NA3360 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207L00000X , with the licence number: NA2772 , 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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