1164635470 NPI number — SANTA MONICA PREVENTIVE CARDIOLOGY MEDICAL GROUP, INC

Table of content: (NPI 1164635470)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164635470 NPI number — SANTA MONICA PREVENTIVE CARDIOLOGY MEDICAL GROUP, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SANTA MONICA PREVENTIVE CARDIOLOGY MEDICAL GROUP, INC
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:
RICHARD L. TAW, JR., M.D., INC.
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:
1164635470
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/27/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2021 SANTA MONICA BLVD
Provider Second Line Business Mailing Address:
SUITE 212E
Provider Business Mailing Address City Name:
SANTA MONICA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90404-2208
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-829-4327
Provider Business Mailing Address Fax Number:
310-453-4348

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2021 SANTA MONICA BLVD
Provider Second Line Business Practice Location Address:
SUITE 212E
Provider Business Practice Location Address City Name:
SANTA MONICA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90404-2208
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-829-4327
Provider Business Practice Location Address Fax Number:
310-453-4348
Provider Enumeration Date:
05/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BOYLAN
Authorized Official First Name:
DIANE
Authorized Official Middle Name:
NONE
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
310-829-4327

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  G26846 , 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)





Copyright © 2007-2024 www.npivalidator.com