1215230560 NPI number — DR MIKEL WALK IN CLINIC

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 1215230560 NPI number — DR MIKEL WALK IN CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR MIKEL WALK IN CLINIC
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:
1215230560
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/08/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15791 BEAR VALLEY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HESPERIA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92345-1746
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-949-1231
Provider Business Mailing Address Fax Number:
760-949-1236

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12821 MAIN ST
Provider Second Line Business Practice Location Address:
STE 130
Provider Business Practice Location Address City Name:
HESPERIA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92345-9126
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-947-3184
Provider Business Practice Location Address Fax Number:
760-947-2816
Provider Enumeration Date:
12/08/2010

Additional Information

Authorized Official

Authorized Official Last Name:
ALWIS
Authorized Official First Name:
MIKEL
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESDENT
Authorized Official Telephone Number:
760-221-9298

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X , with the licence number:  A48518 , 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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