1134421712 NPI number — CANYON GATE MEDICAL GROUP

Table of content: (NPI 1134421712)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134421712 NPI number — CANYON GATE MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CANYON GATE MEDICAL GROUP
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:
CANYON GATE MEDICAL GROUP
Provider Other Organization Name Type Code:
3
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:
1134421712
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/02/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2929 N UNIVERSITY DR
Provider Second Line Business Mailing Address:
SUITE# 110
Provider Business Mailing Address City Name:
CORAL SPRINGS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33065-5081
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
775-751-0695
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
330 S LOLA LN
Provider Second Line Business Practice Location Address:
SUITE# 200
Provider Business Practice Location Address City Name:
PAHRUMP
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89048-0884
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-656-8855
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/02/2010

Additional Information

Authorized Official

Authorized Official Last Name:
COLON
Authorized Official First Name:
VERONICA
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING COORDINATOR
Authorized Official Telephone Number:
954-656-8855

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  936 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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