1164552378 NPI number — CENTINELA VALLEY IPA MEDICAL GROUP


Table of content for CENTINELA VALLEY IPA MEDICAL GROUP (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:
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Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
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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 .

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