1770654378 NPI number — RENEE LAURITZEN MD A PROFESSIONAL CORPORATION

Table of content: (NPI 1770654378)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770654378 NPI number — RENEE LAURITZEN MD A PROFESSIONAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RENEE LAURITZEN MD 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:
PACIFIC ORTHOPEDICS AND SPORTS MEDICINE
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:
1770654378
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/28/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1500 PALM ST
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
SAN LUIS OBISPO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93401-2998
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-542-9678
Provider Business Mailing Address Fax Number:
805-542-9685

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1500 PALM ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
SAN LUIS OBISPO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93401-2998
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-542-9678
Provider Business Practice Location Address Fax Number:
805-542-9685
Provider Enumeration Date:
11/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LAURITZEN
Authorized Official First Name:
RENEE
Authorized Official Middle Name:
S
Authorized Official Title or Position:
DOCTOR
Authorized Official Telephone Number:
805-542-9678

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  G77320 , 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: 00G773200 . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: G77320 . This is a "BLUE CROSS" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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