1659870228 NPI number — CITRUS VALLEY PHYSICIAN PARTNERS

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 1659870228 NPI number — CITRUS VALLEY PHYSICIAN PARTNERS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CITRUS VALLEY PHYSICIAN PARTNERS
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:
1659870228
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/08/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1325 N GRAND AVE STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COVINA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91724-4046
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-732-3159
Provider Business Mailing Address Fax Number:
626-732-3194

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
412 W CARROLL AVE STE 107
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLENDORA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91741-4708
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-914-4890
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/08/2018

Additional Information

Authorized Official

Authorized Official Last Name:
HADDAD
Authorized Official First Name:
CHRISTINE
Authorized Official Middle Name:
Authorized Official Title or Position:
ASSIST. DIRECTOR OF AMBULATORY BUS.
Authorized Official Telephone Number:
626-732-3159

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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