1326166018 NPI number — JOHN ROBERT MORALES CP, BOCO

Table of content: JOHN ROBERT MORALES CP, BOCO (NPI 1326166018)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326166018 NPI number — JOHN ROBERT MORALES CP, BOCO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MORALES
Provider First Name:
JOHN
Provider Middle Name:
ROBERT
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CP, BOCO
Provider Gender Code:
M

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:
1326166018
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
65 MONTGOMERY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANTA ROSA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95404-6616
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-544-5347
Provider Business Mailing Address Fax Number:
707-544-5349

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
65 MONTGOMERY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA ROSA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95404-6616
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-544-5347
Provider Business Practice Location Address Fax Number:
707-544-5349
Provider Enumeration Date:
03/27/2007

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: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: XB0013930 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 68-0179199 . This is a "OTHER" identifier . This identifiers is of the category "OTHER".




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