1164552378 NPI number — CENTINELA VALLEY IPA MEDICAL GROUP

Table of content: (NPI 1164552378)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164552378 NPI number — CENTINELA VALLEY IPA MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTINELA VALLEY IPA 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:
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:
1164552378
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4069
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COVINA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91723-0469
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-971-6717
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
955 OVERLAND CT FL 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN DIMAS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91773-1718
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-971-6717
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/06/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MITCHELL
Authorized Official First Name:
ANITHA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
310-673-9499

Provider Taxonomy Codes

  • Taxonomy code: 171W00000X , with the licence number:  171W00000X , 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)