1770711848 NPI number — INDEPENDENCE COMMUNITY TREATMENT CLINIC

Table of content: MARY ANN NORRIS NP (NPI 1285878918)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770711848 NPI number — INDEPENDENCE COMMUNITY TREATMENT CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INDEPENDENCE COMMUNITY TREATMENT CLINIC
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:
1770711848
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/08/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19231 VICTORY BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RESEDA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91335-6308
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-776-1755
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
43520 DIVISION ST
Provider Second Line Business Practice Location Address:
202, CONFERENCE ROOM
Provider Business Practice Location Address City Name:
LANCASTER
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93535-4089
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-776-1755
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/29/2009

Additional Information

Authorized Official

Authorized Official Last Name:
BRANZBURG
Authorized Official First Name:
ALEX
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE PROGRAM DIRECTOR
Authorized Official Telephone Number:
818-776-1755

Provider Taxonomy Codes

  • Taxonomy code: 261QC1500X , with the licence number:  960001358 , 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: CMM70956F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 196856000 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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