1841209889 NPI number — ELEANOR A WALLEN DPM 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 1841209889 NPI number — ELEANOR A WALLEN DPM INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELEANOR A WALLEN DPM 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:
1841209889
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4418 VINELAND AVENUE
Provider Second Line Business Mailing Address:
SUITE 215
Provider Business Mailing Address City Name:
TOLUCA LAKE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91602-2159
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-980-3383
Provider Business Mailing Address Fax Number:
818-980-5383

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4418 VINELAND AVENUE
Provider Second Line Business Practice Location Address:
SUITE 215
Provider Business Practice Location Address City Name:
TOLUCA LAKE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91602-2159
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-980-3383
Provider Business Practice Location Address Fax Number:
818-980-5383
Provider Enumeration Date:
08/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WALLEN
Authorized Official First Name:
ELEANOR
Authorized Official Middle Name:
ANDREA
Authorized Official Title or Position:
OWNER AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
818-980-3383

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  E3573 , 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)





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