1174621577 NPI number — JEHAN MIR , A PROFESSIONAL MEDICAL CORPORATION

Table of content: (NPI 1174621577)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174621577 NPI number — JEHAN MIR , A PROFESSIONAL MEDICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JEHAN MIR , A PROFESSIONAL MEDICAL CORPORATION
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:
1174621577
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
417 VIA ANITA
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
REDONDO BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90277-6623
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-375-1055
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
301 N PRAIRIE AVE STE 120
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INGLEWOOD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90301-4515
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-677-6101
Provider Business Practice Location Address Fax Number:
310-677-0327
Provider Enumeration Date:
09/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MIR
Authorized Official First Name:
JEHAN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
310-375-1055

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; 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