1851758940 NPI number — BLUE OAK MEDICAL GROUP

Table of content: (NPI 1851758940)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851758940 NPI number — BLUE OAK MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLUE OAK MEDICAL GROUP
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:
1851758940
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/04/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10801 NATIONAL BLVD STE 401
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90064-4143
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:
44105 JACKSON ST STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDIO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-204-6610
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/21/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CHORN
Authorized Official First Name:
ROBIN
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
424-258-5716

Provider Taxonomy Codes

  • Taxonomy code: 261QX0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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