1528096393 NPI number — MR. MARC FABIAN NORCROSS MA, ATC

Table of content: MR. MARC FABIAN NORCROSS MA, ATC (NPI 1528096393)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528096393 NPI number — MR. MARC FABIAN NORCROSS MA, ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NORCROSS
Provider First Name:
MARC
Provider Middle Name:
FABIAN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MA, ATC
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:
1528096393
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:
1703 1/2 MANHATTAN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HERMOSA BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90254-3456
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-372-7387
Provider Business Mailing Address Fax Number:
310-206-1985

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
UCLA ATHLETIC DEPARTMENT
Provider Second Line Business Practice Location Address:
325 WESTWOOD PLAZA
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90095-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-825-3335
Provider Business Practice Location Address Fax Number:
310-206-6107
Provider Enumeration Date:
06/29/2006

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: 2255A2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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