1578574125 NPI number — RANCHO URGENT CARE PHCY

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578574125 NPI number — RANCHO URGENT CARE PHCY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RANCHO URGENT CARE PHCY
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:
1578574125
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:
10841 WHITE OAK AVE
Provider Second Line Business Mailing Address:
STE 101
Provider Business Mailing Address City Name:
RANCHO CUCAMONGA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91730-3811
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10841 WHITE OAK AVE
Provider Second Line Business Practice Location Address:
STE 101
Provider Business Practice Location Address City Name:
RANCHO CUCAMONGA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91730-3811
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-481-7501
Provider Business Practice Location Address Fax Number:
909-980-4376
Provider Enumeration Date:
08/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
OVSEPYAN
Authorized Official First Name:
GILBERT
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
818-653-0404

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  PHY47439 , 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: 5622697 . This is a "OTHER ID NUMBER-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".




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