1689029670 NPI number — PRODIUS, INC.

Table of content: (NPI 1689029670)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689029670 NPI number — PRODIUS, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRODIUS, 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:
1689029670
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/27/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
419 MAIN ST # 312
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HUNTINGTON BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92648-5199
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-867-7883
Provider Business Mailing Address Fax Number:
844-228-9778

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16561 BOLSA CHICA ST STE 106
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUNTINGTON BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92649-3574
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-377-4313
Provider Business Practice Location Address Fax Number:
844-228-9778
Provider Enumeration Date:
04/27/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
REARDON
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
C
Authorized Official Title or Position:
FOUNDER/PRESIDENT
Authorized Official Telephone Number:
714-867-7883

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  16989 , 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)