1245338102 NPI number — MS. GINELLE VILA-DULAY FAJARDO P.T.

Table of content: MS. GINELLE VILA-DULAY FAJARDO P.T. (NPI 1245338102)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245338102 NPI number — MS. GINELLE VILA-DULAY FAJARDO P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FAJARDO
Provider First Name:
GINELLE
Provider Middle Name:
VILA-DULAY
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
P.T.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DULAY
Provider Other First Name:
GINELLE
Provider Other Middle Name:
VILA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
P.T.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1245338102
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/16/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2311 S MIRA CT UNIT 127
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANAHEIM
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92802-3532
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-971-8763
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
215 N STATE COLLEGE BLVD
Provider Second Line Business Practice Location Address:
SUITE G
Provider Business Practice Location Address City Name:
ANAHEIM
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92806-2932
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-999-6596
Provider Business Practice Location Address Fax Number:
714-999-5009
Provider Enumeration Date:
09/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT29347 , 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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