1194746248 NPI number — ULTIMATE LIVING MEDICAL CLINIC, PROF. CORP.

Table of content: JUSTIN BADER PT, DPT (NPI 1245630540)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194746248 NPI number — ULTIMATE LIVING MEDICAL CLINIC, PROF. CORP.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ULTIMATE LIVING MEDICAL CLINIC, PROF. 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:
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:
1194746248
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1660 E HERNDON AVE
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
FRESNO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93720-3359
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
559-435-8000
Provider Business Mailing Address Fax Number:
559-380-2879

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1660 E HERNDON AVE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
FRESNO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93720-3359
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-435-8000
Provider Business Practice Location Address Fax Number:
559-380-2879
Provider Enumeration Date:
07/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WORK
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
RALPH
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
559-435-8000

Provider Taxonomy Codes

  • Taxonomy code: 208VP0000X , with the licence number:  A66593 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207QA0505X , with the licence number: A66593 , 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)





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