1740506781 NPI number — DEEPAL CEMO MEDICAL SOLUTIONS, LLC

Table of content: (NPI 1740506781)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740506781 NPI number — DEEPAL CEMO MEDICAL SOLUTIONS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEEPAL CEMO MEDICAL SOLUTIONS, LLC
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:
AMERICAN DIABETES THERAPY CENTERS
Provider Other Organization Name Type Code:
3
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:
1740506781
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/03/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
950 GLENN DR
Provider Second Line Business Mailing Address:
SUITE 250
Provider Business Mailing Address City Name:
FOLSOM
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95630-3130
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-933-2300
Provider Business Mailing Address Fax Number:
916-933-0119

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
945 ROSEVILLE PARKWAY
Provider Second Line Business Practice Location Address:
SUITE 150
Provider Business Practice Location Address City Name:
ROSEVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95678-6063
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-788-8444
Provider Business Practice Location Address Fax Number:
916-788-8449
Provider Enumeration Date:
04/15/2010

Additional Information

Authorized Official

Authorized Official Last Name:
ZWECK
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
916-933-2300

Provider Taxonomy Codes

  • Taxonomy code: 261QI0500X , with the licence number:  CLR339743 , 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: 05D2005230 . This is a "CLIA WAIVER" identifier . This identifiers is of the category "OTHER".
  • Identifier: CLR 339743 . This is a "CALIFORNIA CLIA REGISTRATION" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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