1770894420 NPI number — KAREN GENCO PA

Table of content: KAREN GENCO PA (NPI 1770894420)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770894420 NPI number — KAREN GENCO PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GENCO
Provider First Name:
KAREN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RUDD
Provider Other First Name:
KAREN
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1770894420
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/28/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4646 BROCKTON AVE
Provider Second Line Business Mailing Address:
STE 203
Provider Business Mailing Address City Name:
RIVERSIDE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92506-0102
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-774-2870
Provider Business Mailing Address Fax Number:
951-774-2874

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4646 BROCKTON AVE
Provider Second Line Business Practice Location Address:
STE 203
Provider Business Practice Location Address City Name:
RIVERSIDE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92506-0102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-774-2870
Provider Business Practice Location Address Fax Number:
951-774-2874
Provider Enumeration Date:
06/28/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA16059 , 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)