1306888631 NPI number — HEALTH ENTERPRISES

Table of content: (NPI 1306888631)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306888631 NPI number — HEALTH ENTERPRISES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEALTH ENTERPRISES
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:
6
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:
1306888631
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/25/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
22573 BARTON RD STE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND TERRACE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92313-5203
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-883-0288
Provider Business Mailing Address Fax Number:
888-836-9159

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22573 BARTON RD STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND TERRACE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92313-5203
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-883-0288
Provider Business Practice Location Address Fax Number:
909-883-5088
Provider Enumeration Date:
06/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ENZENBACHER
Authorized Official First Name:
JOE
Authorized Official Middle Name:
Authorized Official Title or Position:
ASSISTANT ADMINISTRATOR
Authorized Official Telephone Number:
909-883-0288

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  240000615 , 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: HHA57680G , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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