1063931269 NPI number — GOLAN INTEGRATED PHYSICAL MEDICINE

Table of content: ROSAURA VASQUEZ HENRIQUEZ RBT (NPI 1033932603)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063931269 NPI number — GOLAN INTEGRATED PHYSICAL MEDICINE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GOLAN INTEGRATED PHYSICAL MEDICINE
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:
1063931269
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/25/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2100 E CALVADA BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PAHRUMP
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89048-5805
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
775-727-7959
Provider Business Mailing Address Fax Number:
775-727-7960

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2100 E CALVADA BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PAHRUMP
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89048-5805
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
775-727-7959
Provider Business Practice Location Address Fax Number:
775-727-7960
Provider Enumeration Date:
09/19/2017

Additional Information

Authorized Official

Authorized Official Last Name:
CHRISTENSEN
Authorized Official First Name:
ANNA
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
775-727-7959

Provider Taxonomy Codes

  • Taxonomy code: 208100000X , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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