1386827988 NPI number — GUSTAFSON ORTHOPEDICS, 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 1386827988 NPI number — GUSTAFSON ORTHOPEDICS, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GUSTAFSON ORTHOPEDICS, 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:
1386827988
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/11/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1056
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOMA LINDA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92354-1056
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-478-5600
Provider Business Mailing Address Fax Number:
909-478-5601

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10459 MT VIEW AVE
Provider Second Line Business Practice Location Address:
STE. B
Provider Business Practice Location Address City Name:
LOMA LINDA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92354-2033
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-478-5600
Provider Business Practice Location Address Fax Number:
909-478-5601
Provider Enumeration Date:
12/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ZIOLA
Authorized Official First Name:
TAMMI
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL BILLER
Authorized Official Telephone Number:
909-478-5600

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  G24086 , 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: ZZZ28798Z . This is a "MEDICARE PROVIDER #" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 00G240860 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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