1568679397 NPI number — SABLAN MEDICAL CORPORATION

Table of content: (NPI 1568679397)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568679397 NPI number — SABLAN MEDICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SABLAN 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:
SABLAN MEDICAL CLINIC
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:
1568679397
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/13/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 306
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FIREBAUGH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93622-0306
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
559-296-5080
Provider Business Mailing Address Fax Number:
559-296-5011

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
979 O ST
Provider Second Line Business Practice Location Address:
STE B
Provider Business Practice Location Address City Name:
FIREBAUGH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93622-2220
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-296-5080
Provider Business Practice Location Address Fax Number:
559-296-5011
Provider Enumeration Date:
05/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SABLAN
Authorized Official First Name:
OSCAR
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
559-296-5080

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  G45421 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: G45391 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR1300X , with the licence number: G45421 , 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: RHM03903F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: BCP03903F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: HAP03903F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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