1154306231 NPI number — SOLARA MEDICAL SUPPLIES, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154306231 NPI number — SOLARA MEDICAL SUPPLIES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOLARA MEDICAL SUPPLIES, LLC
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:
1154306231
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/19/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2084 OTAY LAKES RD STE 102
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHULA VISTA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91913-1368
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-999-7516
Provider Business Mailing Address Fax Number:
800-999-7021

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
720 HWY 75
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IMPERIAL BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91932
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-424-8143
Provider Business Practice Location Address Fax Number:
619-424-8652
Provider Enumeration Date:
12/12/2005

Additional Information

Authorized Official

Authorized Official Last Name:
ROBINSON
Authorized Official First Name:
TOD
Authorized Official Middle Name:
JEFFREY
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
858-259-8287

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X , with the licence number: PHY46235 , 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)

  • Identifier: PHA462350 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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