1396920047 NPI number — HOME PORTABLE X-RAY

Table of content: (NPI 1396920047)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396920047 NPI number — HOME PORTABLE X-RAY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HOME PORTABLE X-RAY
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:
1396920047
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/31/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
801 MAPLE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN MATEO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94402
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
650-703-9701
Provider Business Mailing Address Fax Number:
650-342-8379

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30 SO EL CAMINO REAL
Provider Second Line Business Practice Location Address:
SUITE 109
Provider Business Practice Location Address City Name:
SAN MATEO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
650-347-1880
Provider Business Practice Location Address Fax Number:
650-342-8379
Provider Enumeration Date:
12/31/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CROUSE
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
WM
Authorized Official Title or Position:
OWNER OPERATOR
Authorized Official Telephone Number:
650-347-1880

Provider Taxonomy Codes

  • Taxonomy code: 335V00000X , with the licence number:  RHT3605 , 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: ZZZ31682Z , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZ31682Z . This is a "MEDICARE PROV ID" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ31682Z . This is a "MEDICAID PROV ID" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".