1174670210 NPI number — ENNEAD ENTERPRISES CORP

Table of content: (NPI 1174670210)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174670210 NPI number — ENNEAD ENTERPRISES CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ENNEAD ENTERPRISES CORP
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:
SC PHYSICIANS IMMEDIATE CARE
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:
1174670210
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:
26012 OHARA LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STEVENSON RANCH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91381-1109
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
661-255-6920
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
23501 CINEMA DR.
Provider Second Line Business Practice Location Address:
SUIRE #100
Provider Business Practice Location Address City Name:
VALENCIA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91355
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
661-255-2880
Provider Business Practice Location Address Fax Number:
661-255-2190
Provider Enumeration Date:
01/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MARSHALL
Authorized Official First Name:
LILLY
Authorized Official Middle Name:
ROSE
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
661-255-2880

Provider Taxonomy Codes

  • Taxonomy code: 261QU0200X , with the licence number:  G52007 , 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