1346697471 NPI number — 12TH STREET OPERATIONS, LLC

Table of content: (NPI 1346697471)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346697471 NPI number — 12TH STREET OPERATIONS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
12TH STREET OPERATIONS, LLC
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:
PIONEER HEALTH CARE CENTER
Provider Other Organization Name Type Code:
3
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:
1346697471
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/07/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
26522 LA ALAMEDA STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MISSION VIEJO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92691-8302
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-449-2500
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
900 S 12TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCKY FORD
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81067-2128
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-876-9252
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/18/2016

Additional Information

Authorized Official

Authorized Official Last Name:
SILVER
Authorized Official First Name:
RACHEL
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF A/R-COLORADO
Authorized Official Telephone Number:
619-876-9252

Provider Taxonomy Codes

  • Taxonomy code: 261QR0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 385H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 33155071 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9000142633 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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