1881021848 NPI number — INTEGRATED HEALTH CENTER OF ROSEVILLE PC

Table of content: MS. JENNIFER GWEN EVANS DPT (NPI 1982065579)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881021848 NPI number — INTEGRATED HEALTH CENTER OF ROSEVILLE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTEGRATED HEALTH CENTER OF ROSEVILLE PC
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:
1881021848
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/30/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1411 SECRET RAVINE PKWY
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
ROSEVILLE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95661-6041
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-786-2002
Provider Business Mailing Address Fax Number:
916-786-2003

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1411 SECRET RAVINE PKWY
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
ROSEVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95661-6041
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-786-2002
Provider Business Practice Location Address Fax Number:
916-786-2003
Provider Enumeration Date:
10/04/2013

Additional Information

Authorized Official

Authorized Official Last Name:
LEIGH
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
G
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
480-550-1750

Provider Taxonomy Codes

  • Taxonomy code: 208100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: ZZZ81379Y . This is a "BCBS" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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