1275843369 NPI number — ACADEMIA MODERNA

Table of content: (NPI 1275843369)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275843369 NPI number — ACADEMIA MODERNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ACADEMIA MODERNA
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:
1275843369
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/07/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2410 BROADWAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WALNUT PARK
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90255-6342
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
323-251-7123
Provider Business Mailing Address Fax Number:
323-588-5354

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2410 BROADWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WALNUT PARK
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90255-6342
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-251-7123
Provider Business Practice Location Address Fax Number:
323-588-5354
Provider Enumeration Date:
10/07/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
REYES
Authorized Official First Name:
XAVIER
Authorized Official Middle Name:
Authorized Official Title or Position:
SCHOOL ADMINISTRATOR
Authorized Official Telephone Number:
323-251-7123

Provider Taxonomy Codes

  • Taxonomy code: 251300000X , with the licence number:  0120097 , 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)

  • Identifier: 0120097 . This is a "LEA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 19 64733 0120097 . This is a "CDS CODE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".