1609193705 NPI number — MISSION MEDICAL ASSOCIATES, INC.

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 1609193705 NPI number — MISSION MEDICAL ASSOCIATES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MISSION MEDICAL ASSOCIATES, INC.
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:
1609193705
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/28/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20377 SW ACACIA ST STE 110
Provider Second Line Business Mailing Address:
ATTN: R TAYLOR
Provider Business Mailing Address City Name:
NEWPORT BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92660-0781
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-870-3617
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6276 RIVER CREST DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIVERSIDE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92507-0783
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-413-0979
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/28/2010

Additional Information

Authorized Official

Authorized Official Last Name:
TAYLOR
Authorized Official First Name:
RANDOLPH
Authorized Official Middle Name:
Authorized Official Title or Position:
SECRETARY
Authorized Official Telephone Number:
949-870-3617

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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