1689994246 NPI number — WATSONVILLE MEDICAL CLINIC AND AESTHETIC CLINIC, INC

Table of content: (NPI 1689994246)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689994246 NPI number — WATSONVILLE MEDICAL CLINIC AND AESTHETIC CLINIC, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WATSONVILLE MEDICAL CLINIC AND AESTHETIC CLINIC, 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:
1689994246
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/07/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
284 PENNSYLVANIA DR
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
WATSONVILLE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95076-3768
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
831-722-8787
Provider Business Mailing Address Fax Number:
831-722-8881

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
284 PENNSYLVANIA DR
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
WATSONVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95076-3768
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
831-722-8787
Provider Business Practice Location Address Fax Number:
831-722-8881
Provider Enumeration Date:
06/07/2010

Additional Information

Authorized Official

Authorized Official Last Name:
MAR
Authorized Official First Name:
HUGO
Authorized Official Middle Name:
GERARDO
Authorized Official Title or Position:
PHYSICIAN ASSISTANT
Authorized Official Telephone Number:
831-722-8787

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  A80671 , 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: PA13256 . This is a "PHYSICIAN ASSISTANT NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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