1689811069 NPI number — SOUTHERN CALIFORNIA MEDICAL SPECIALISTS, INC.

Table of content: KAYLA ANNE FOGLE LPCC (NPI 1356763551)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689811069 NPI number — SOUTHERN CALIFORNIA MEDICAL SPECIALISTS, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN CALIFORNIA MEDICAL SPECIALISTS, 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:
1689811069
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/07/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1625 E 17TH ST STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANTA ANA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92705-8517
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-543-9555
Provider Business Mailing Address Fax Number:
714-543-9595

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1625 E 17TH ST STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA ANA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92705-8517
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-543-9555
Provider Business Practice Location Address Fax Number:
714-543-9595
Provider Enumeration Date:
01/07/2009

Additional Information

Authorized Official

Authorized Official Last Name:
DESHMUKH
Authorized Official First Name:
VAISHALI
Authorized Official Middle Name:
SANJAY
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
714-543-9555

Provider Taxonomy Codes

  • Taxonomy code: 261QM2500X , with the licence number:  A65424 , 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)





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