1811641244 NPI number — MINUTECLINIC DIAGNOSTIC MEDICAL GROUP OF CALIFORNIA INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811641244 NPI number — MINUTECLINIC DIAGNOSTIC MEDICAL GROUP OF CALIFORNIA INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MINUTECLINIC DIAGNOSTIC MEDICAL GROUP OF CALIFORNIA 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:
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:
1811641244
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/11/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 772
Provider Second Line Business Mailing Address:
MC 2295
Provider Business Mailing Address City Name:
WOONSOCKET
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02895-0784
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
511 N HOLLYWOOD WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURBANK
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91505-3406
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
855-417-2486
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/04/2022

Additional Information

Authorized Official

Authorized Official Last Name:
PINCINCE
Authorized Official First Name:
DEBORAH
Authorized Official Middle Name:
JEAN
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
401-770-3813

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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