1770685612 NPI number — SANTO NINO MEDICAL GROUP INC

Table of content: (NPI 1770685612)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770685612 NPI number — SANTO NINO MEDICAL GROUP INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SANTO NINO MEDICAL GROUP INC
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:
SANTO NINO MEDICAL CLINIC
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:
1770685612
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/14/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14427 CHASE ST
Provider Second Line Business Mailing Address:
STE. 100
Provider Business Mailing Address City Name:
PANORAMA CITY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91402-3020
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-830-7751
Provider Business Mailing Address Fax Number:
818-891-7892

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14427 CHASE ST
Provider Second Line Business Practice Location Address:
STE. 100
Provider Business Practice Location Address City Name:
PANORAMA CITY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91402-3020
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-830-7751
Provider Business Practice Location Address Fax Number:
818-891-7892
Provider Enumeration Date:
09/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MARSHAK
Authorized Official First Name:
GLENN
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT / OWNER
Authorized Official Telephone Number:
818-830-7751

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  A44687 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207Q00000X , with the licence number: PA15625 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: C50675 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208D00000X , with the licence number: G080659 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: PA21838 , 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: GR0092750 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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