1538125059 NPI number — SHIRLEY M CHAN M D A MEDICAL CORPORATION

Table of content: (NPI 1538125059)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538125059 NPI number — SHIRLEY M CHAN M D A MEDICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHIRLEY M CHAN M D A MEDICAL CORPORATION
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:
1538125059
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/23/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 80305
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CITY OF INDUSTRY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91716-8305
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-243-8431
Provider Business Mailing Address Fax Number:
818-247-9239

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1505 WILSON TERRACE
Provider Second Line Business Practice Location Address:
STE 350
Provider Business Practice Location Address City Name:
GLENDALE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91206-4072
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-243-8431
Provider Business Practice Location Address Fax Number:
818-247-9239
Provider Enumeration Date:
04/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CHAN
Authorized Official First Name:
SHIRLEY
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
818-243-8431

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  G58168 , 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)

  • Identifier: 00G581680 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com