1336215474 NPI number — SEVENTEENTH STREET ORTHOPEDIC SPECIALTY MEDICAL CLINIC, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336215474 NPI number — SEVENTEENTH STREET ORTHOPEDIC SPECIALTY MEDICAL CLINIC, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SEVENTEENTH STREET ORTHOPEDIC SPECIALTY MEDICAL CLINIC, INC
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:
1336215474
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1450 E 17TH ST
Provider Second Line Business Mailing Address:
# 100
Provider Business Mailing Address City Name:
SANTA ANA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92705-8510
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-565-1000
Provider Business Mailing Address Fax Number:
714-565-1974

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1450 E 17TH ST
Provider Second Line Business Practice Location Address:
# 100
Provider Business Practice Location Address City Name:
SANTA ANA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92705-8510
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-565-1000
Provider Business Practice Location Address Fax Number:
714-565-1974
Provider Enumeration Date:
11/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BROURMAN
Authorized Official First Name:
PHYLLIS
Authorized Official Middle Name:
R
Authorized Official Title or Position:
ATTORNEY
Authorized Official Telephone Number:
310-657-2202

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com