1457495046 NPI number — FALLBROOK MEDICAL GROUP, INC

Table of content: (NPI 1457495046)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457495046 NPI number — FALLBROOK MEDICAL GROUP, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FALLBROOK MEDICAL GROUP, 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:
FALLBROOK MEDICAL ASSOCIATES
Provider Other Organization Name Type Code:
3
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:
1457495046
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:
504 E ALVARADO ST STE 201
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FALLBROOK
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92028-2364
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-731-0352
Provider Business Mailing Address Fax Number:
760-731-2151

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
504 E ALVARADO ST STE 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FALLBROOK
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92028-2364
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-731-0352
Provider Business Practice Location Address Fax Number:
760-731-2151
Provider Enumeration Date:
02/16/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GORDON
Authorized Official First Name:
BARBARA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE ADMINISTRATOR
Authorized Official Telephone Number:
760-731-0352

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  G23092 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 207R00000X , with the licence number: C36017 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 208000000X , with the licence number: G36388 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: GR00666880 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".