1174679211 NPI number — THERAPEUTIC ADVANTAGE INCORPORATED

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174679211 NPI number — THERAPEUTIC ADVANTAGE INCORPORATED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THERAPEUTIC ADVANTAGE INCORPORATED
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:
THERAPEUTIC ADVANTAGE, INC.
Provider Other Organization Name Type Code:
5
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:
1174679211
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/25/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19191 S VERMONT AVE
Provider Second Line Business Mailing Address:
SUITE 410
Provider Business Mailing Address City Name:
TORRANCE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90502-1018
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-327-9101
Provider Business Mailing Address Fax Number:
310-327-6611

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19191 S VERMONT AVE
Provider Second Line Business Practice Location Address:
SUITE 410
Provider Business Practice Location Address City Name:
TORRANCE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90502-1018
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-327-9101
Provider Business Practice Location Address Fax Number:
310-327-6611
Provider Enumeration Date:
01/25/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HOFFMAN
Authorized Official First Name:
GRACE
Authorized Official Middle Name:
IMPERIAL
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
310-327-9101

Provider Taxonomy Codes

  • Taxonomy code: 2251G0304X , with the licence number:  26393 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225X00000X , with the licence number: 6118 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: W16201 . This is a "GROUP ID NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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