1417512344 NPI number — ILIANA ANGELICA GONZALEZ MEDINA BCBA

Table of content: ILIANA ANGELICA GONZALEZ MEDINA BCBA (NPI 1417512344)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417512344 NPI number — ILIANA ANGELICA GONZALEZ MEDINA BCBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GONZALEZ MEDINA
Provider First Name:
ILIANA
Provider Middle Name:
ANGELICA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
BCBA
Provider Gender Code:
F

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:
1417512344
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/01/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 33568
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92163-3568
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
552-237-1238
Provider Business Mailing Address Fax Number:
619-374-7134

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1295 CORONA POINTE CT STE 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORONA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92879-1721
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
855-223-7123
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/06/2019

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: 103K00000X , with the licence number:  12261129 , 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)





Copyright © 2007-2024 www.npivalidator.com