1659494557 NPI number — STEPHANI SIMON LUECKER D.O.

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 1659494557 NPI number — STEPHANI SIMON LUECKER D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LUECKER
Provider First Name:
STEPHANI
Provider Middle Name:
SIMON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SIMON
Provider Other First Name:
STEPHANI
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1659494557
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/19/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 660446
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ARCADIA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91066-0446
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-447-0296
Provider Business Mailing Address Fax Number:
626-447-6057

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1145 W REDONDO BEACH BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GARDENA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90247-3528
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-538-6629
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/08/2007

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: 207P00000X , with the licence number:  20A11735 , 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: 20A11735 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com