1205311479 NPI number — METICULOUS MEDICAL, INC.

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 1205311479 NPI number — METICULOUS MEDICAL, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
METICULOUS MEDICAL, INC.
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:
1205311479
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/16/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
672 WEST 11TH STREET
Provider Second Line Business Mailing Address:
SUITE 323
Provider Business Mailing Address City Name:
TRACY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95376
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
833-638-6331
Provider Business Mailing Address Fax Number:
559-453-0107

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
672 WEST 11TH STREET
Provider Second Line Business Practice Location Address:
SUITE 323
Provider Business Practice Location Address City Name:
TRACY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95376
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
833-638-6331
Provider Business Practice Location Address Fax Number:
559-453-0107
Provider Enumeration Date:
10/03/2018

Additional Information

Authorized Official

Authorized Official Last Name:
MCCAMEY
Authorized Official First Name:
JASON
Authorized Official Middle Name:
JERRY
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
559-593-2451

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 98717 . This is a "HOME MEDICAL DEVICE DETAIL LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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