1861839565 NPI number — EVANGELINE A. GIMBEL, MD INC.

Table of content: KELLY MRAZ CCC-SLP (NPI 1841351657)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861839565 NPI number — EVANGELINE A. GIMBEL, MD INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EVANGELINE A. GIMBEL, MD 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:
1861839565
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/04/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7950 CHERRY AVE
Provider Second Line Business Mailing Address:
SUITE 105
Provider Business Mailing Address City Name:
FONTANA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92336-4022
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-434-1657
Provider Business Mailing Address Fax Number:
909-231-6231

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7950 CHERRY AVE
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
FONTANA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92336-4022
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-434-1657
Provider Business Practice Location Address Fax Number:
909-231-6231
Provider Enumeration Date:
06/04/2013

Additional Information

Authorized Official

Authorized Official Last Name:
GIMBEL
Authorized Official First Name:
EVANGELINE
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
909-434-1657

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  A50667 , 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: 00A506670 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com