1700970753 NPI number — RESTORE MEDICAL GROUP, A PROFESSIONAL CORPORATION

Table of content: (NPI 1700970753)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700970753 NPI number — RESTORE MEDICAL GROUP, A PROFESSIONAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RESTORE MEDICAL GROUP, A PROFESSIONAL CORPORATION
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:
1700970753
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/18/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 261399
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ENCINO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91426-1399
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-786-9417
Provider Business Mailing Address Fax Number:
818-786-9419

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16400 VENTURA BLVD
Provider Second Line Business Practice Location Address:
SUITE 328
Provider Business Practice Location Address City Name:
ENCINO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91436-2137
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-786-9417
Provider Business Practice Location Address Fax Number:
818-786-9419
Provider Enumeration Date:
10/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
COPPELSON
Authorized Official First Name:
AAARON
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
818-786-9417

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  A76120 , 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: 1891775235 . This is a "NPI" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1171563 . This is a "CAQH" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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