1871841692 NPI number — MMJ MEDICAL INC,

Table of content: DR. SETH KUNEN PH.D., PSY.D. (NPI 1073689378)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871841692 NPI number — MMJ MEDICAL INC,

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MMJ MEDICAL 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:
6
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:
1871841692
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/16/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
29 PRAIRIE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IRVINE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92618-8840
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-825-5188
Provider Business Mailing Address Fax Number:
949-825-5189

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1810 FULLERTON AVE
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
CORONA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92881
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-934-0505
Provider Business Practice Location Address Fax Number:
951-934-0506
Provider Enumeration Date:
08/28/2012

Additional Information

Authorized Official

Authorized Official Last Name:
JAMAL
Authorized Official First Name:
MOHAMMAD MAZEN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
949-813-5115

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  A46078 , 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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