1265481873 NPI number — NISSIM INSTITUTIONAL PROVIDERS

Table of content: (NPI 1265481873)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265481873 NPI number — NISSIM INSTITUTIONAL PROVIDERS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NISSIM INSTITUTIONAL PROVIDERS
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:
1265481873
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/06/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2701 KIMBALL AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POMONA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91767-2268
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-447-7040
Provider Business Mailing Address Fax Number:
909-447-7030

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9612 VAN NUYS BLVD
Provider Second Line Business Practice Location Address:
#108
Provider Business Practice Location Address City Name:
PANORAMA CITY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91402-1044
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-447-7040
Provider Business Practice Location Address Fax Number:
909-447-7030
Provider Enumeration Date:
05/09/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WEISS
Authorized Official First Name:
HOWARD
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
818-892-4555

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332BN1400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BP3500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: DME01561F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".