1417047069 NPI number — MR. ANTHONY DESANTO-KELLY LICENSE PYSCH TECH 3

Table of content: MR. ANTHONY DESANTO-KELLY LICENSE PYSCH TECH 3 (NPI 1417047069)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417047069 NPI number — MR. ANTHONY DESANTO-KELLY LICENSE PYSCH TECH 3

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DESANTO-KELLY
Provider First Name:
ANTHONY
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LICENSE PYSCH TECH 3
Provider Gender Code:
M

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:
1417047069
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12857 FREDERICK ST APT 304
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MORENO VALLEY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92553-4502
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-653-3141
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3501 N LAKEWOOD BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONG BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90808-1736
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-570-7119
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/13/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 167G00000X , with the licence number:  PT24452 , 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)