1750348033 NPI number — IMPERIAL VALLEY FAMILY CARE MEDICAL GROUP

Table of content: (NPI 1750348033)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750348033 NPI number — IMPERIAL VALLEY FAMILY CARE MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IMPERIAL VALLEY FAMILY CARE 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:
IMPERIAL VALLEY FAMILY CARE MEDICAL GROUP LABORATORY
Provider Other Organization Name Type Code:
5
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:
1750348033
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/24/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
516 WEST ATEN ROAD
Provider Second Line Business Mailing Address:
SUITE 2
Provider Business Mailing Address City Name:
IMPERIAL
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92251
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-355-7730
Provider Business Mailing Address Fax Number:
760-355-7731

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
516 WEST ATEN ROAD
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
IMPERIAL
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92251
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-355-2701
Provider Business Practice Location Address Fax Number:
760-355-8397
Provider Enumeration Date:
04/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PALAKODETI
Authorized Official First Name:
VACHASPATHI
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
760-355-7730

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  05D0681409 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 291U00000X , with the licence number: 05D0973957 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1275581894 . This is a "GROUP NPI" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: LAB81409F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: CC6635 . This is a "RAILROAD GROUP #" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 05D0681409 . This is a "CLIA #" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: P00164275 . This is a "RAIL ROAD PIN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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