1356916290 NPI number — MYOFASCIAL RESTORATION AND INTEGRATION POMC

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 1356916290 NPI number — MYOFASCIAL RESTORATION AND INTEGRATION POMC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MYOFASCIAL RESTORATION AND INTEGRATION POMC
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:
1356916290
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/08/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
155 SAINT GERMAIN LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLEASANT HILL
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94523-1135
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
925-326-8471
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
411 30TH ST STE 314
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OAKLAND
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94609-3312
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
925-326-8471
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/24/2021

Additional Information

Authorized Official

Authorized Official Last Name:
VERCELES
Authorized Official First Name:
EDWARD
Authorized Official Middle Name:
T
Authorized Official Title or Position:
OWNER, AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
925-326-8471

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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