1699248302 NPI number — OH PHUKET

Table of content: (NPI 1699248302)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699248302 NPI number — OH PHUKET

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OH PHUKET
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:
1699248302
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/04/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1406 SCOTT DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NATIONAL CITY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91950-1627
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-865-0445
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
401 RYLAND ST STE 200A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RENO
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89502-1643
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-865-0445
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/04/2019

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
QUIROZ
Authorized Official First Name:
JUAN
Authorized Official Middle Name:
ANTONIO
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
619-865-0445

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 341600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3416A0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3416L0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3416S0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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