1538456090 NPI number — MS. FALLON NASSIEM AGAHI LOPEZ

Table of content: MS. FALLON NASSIEM AGAHI LOPEZ (NPI 1538456090)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538456090 NPI number — MS. FALLON NASSIEM AGAHI LOPEZ

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LOPEZ
Provider First Name:
FALLON
Provider Middle Name:
NASSIEM AGAHI
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
AGAHI
Provider Other First Name:
FALLON
Provider Other Middle Name:
NASSIEM
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1538456090
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/04/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3105 CEDAR RAVINE RD
Provider Second Line Business Mailing Address:
STE 201
Provider Business Mailing Address City Name:
PLACERVILLE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95667-6561
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
530-626-1602
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3301 C ST
Provider Second Line Business Practice Location Address:
BLDG 550
Provider Business Practice Location Address City Name:
SACRAMENTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95816-3300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-556-3164
Provider Business Practice Location Address Fax Number:
916-733-5920
Provider Enumeration Date:
07/06/2011

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: 363A00000X , 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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