1689863995 NPI number — 1ST INDUSTRIAL MEDICAL GROUP

Table of content: (NPI 1689863995)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689863995 NPI number — 1ST INDUSTRIAL MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
1ST INDUSTRIAL MEDICAL GROUP
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:
1689863995
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/24/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1234 W CHAPMAN AVE
Provider Second Line Business Mailing Address:
SUITE # 204
Provider Business Mailing Address City Name:
ORANGE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92868-2862
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-289-4693
Provider Business Mailing Address Fax Number:
714-289-4698

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1234 W CHAPMAN AVE
Provider Second Line Business Practice Location Address:
SUITE 204
Provider Business Practice Location Address City Name:
ORANGE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92868-2862
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-289-4693
Provider Business Practice Location Address Fax Number:
714-289-4698
Provider Enumeration Date:
10/23/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BENNALLACK
Authorized Official First Name:
MARK
Authorized Official Middle Name:
W
Authorized Official Title or Position:
CO OWNER
Authorized Official Telephone Number:
714-289-4693

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207LP2900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207XX0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086S0122X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208G00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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