1881256857 NPI number — TONY DEMICO HARRIS MBR

Table of content: (NPI 1881256857)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881256857 NPI number — TONY DEMICO HARRIS MBR

Organization/Personal Information

Employer Identification Number (EIN):
N/A
Provider Organization Name:
TONY DEMICO HARRIS MBR
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:
1881256857
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/01/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8052 TUSCANY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FONTANA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92336-3800
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-756-3583
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8052 TUSCANY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FONTANA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92336-3800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-756-3583
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/01/2019

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HARRIS
Authorized Official First Name:
TONY
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF EXECTIVE OFFICER
Authorized Official Telephone Number:
909-756-3583

Provider Taxonomy Codes

  • Taxonomy code: 103G00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 177F00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251C00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QC1800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM2800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QS0112X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 305R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 320600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336M0002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 302F00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 005947 . This is a "HEALTHCARE ALLIANCE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".