1861564023 NPI number — GURAVTAR S SIDHU D.C.

Table of content: GURAVTAR S SIDHU D.C. (NPI 1861564023)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861564023 NPI number — GURAVTAR S SIDHU D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SIDHU
Provider First Name:
GURAVTAR
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.C.
Provider Gender Code:
M

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:
1861564023
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/04/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1176
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARDIFF
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92007-7176
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-509-7999
Provider Business Mailing Address Fax Number:
858-901-1346

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
410 S MELROSE DR STE 107
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VISTA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92081
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-295-9000
Provider Business Practice Location Address Fax Number:
858-901-1346
Provider Enumeration Date:
11/14/2006

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: 111N00000X , with the licence number:  DC27365 , 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: GC817A , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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