1447076310 NPI number — SPECIALTY MEDICAL LLC

Table of content: DR. TARA GUEST ARNOLD PHD, LCSW (NPI 1649343732)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447076310 NPI number — SPECIALTY MEDICAL LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPECIALTY MEDICAL LLC
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:
1447076310
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/25/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2680 POMONA BLVD STE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POMONA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91768-3272
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-688-5326
Provider Business Mailing Address Fax Number:
800-619-6826

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2680 POMONA BLVD STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POMONA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91768-3272
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-688-5326
Provider Business Practice Location Address Fax Number:
800-619-6826
Provider Enumeration Date:
11/25/2024

Additional Information

Authorized Official

Authorized Official Last Name:
SULLIVAN
Authorized Official First Name:
DOUG
Authorized Official Middle Name:
DELYLE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
626-688-5326

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PHA420980 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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