1205065570 NPI number — GARRISON FAMILY MEDICAL GROUP CANYON COUNTRY

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 1205065570 NPI number — GARRISON FAMILY MEDICAL GROUP CANYON COUNTRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GARRISON FAMILY MEDICAL GROUP CANYON COUNTRY
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:
1205065570
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/08/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
41210 11TH ST W
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
PALMDALE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93551-1447
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
661-947-7100
Provider Business Mailing Address Fax Number:
661-947-5151

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18520 VIA PRINCESSA
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
CANYON COUNTRY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91387-8326
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-333-2996
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/08/2009

Additional Information

Authorized Official

Authorized Official Last Name:
ABATTI
Authorized Official First Name:
ANTONETTE
Authorized Official Middle Name:
Authorized Official Title or Position:
BUSINESS ADMINISTRATOR
Authorized Official Telephone Number:
661-947-7100

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  G50780 , 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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