1679677629 NPI number — LONG BEACH MEMORIAL MEDICAL

Table of content: (NPI 1679677629)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679677629 NPI number — LONG BEACH MEMORIAL MEDICAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LONG BEACH MEMORIAL MEDICAL
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:
INFUSION CARE PHARMACY SOUTH
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:
1679677629
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/23/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 20359
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONG BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90801-3359
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
562-933-3282
Provider Business Mailing Address Fax Number:
562-933-0014

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
23521 PASEO DE VALENCIA
Provider Second Line Business Practice Location Address:
STE B-1
Provider Business Practice Location Address City Name:
LAGUNA HILLS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92653
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-460-1610
Provider Business Practice Location Address Fax Number:
949-458-0554
Provider Enumeration Date:
09/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FINCH
Authorized Official First Name:
CHRIS
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF COMPLIANCE OFFICER
Authorized Official Telephone Number:
714-377-3218

Provider Taxonomy Codes

  • Taxonomy code: 332BP3500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336H0001X , with the licence number: PHY40530 , 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: PHA40530 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1996335 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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