1417936113 NPI number — PROFESSIONAL HEALTH CARE PROVIDER, 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 1417936113 NPI number — PROFESSIONAL HEALTH CARE PROVIDER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROFESSIONAL HEALTH CARE PROVIDER, 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:
1417936113
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
23443 GOLDEN SPRINGS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DIAMOND BAR
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91765-2030
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-860-3080
Provider Business Mailing Address Fax Number:
909-860-3008

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
23443 GOLDEN SPRINGS DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DIAMOND BAR
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91765-2030
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-860-3080
Provider Business Practice Location Address Fax Number:
909-860-3008
Provider Enumeration Date:
01/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DORADO
Authorized Official First Name:
FE
Authorized Official Middle Name:
CIPRES
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
909-860-3080

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , 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)





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