1891033668 NPI number — SEQUOIA FAMILY MEDICAL GROUP, INC.

Table of content: (NPI 1891033668)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891033668 NPI number — SEQUOIA FAMILY MEDICAL GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SEQUOIA FAMILY MEDICAL GROUP, 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:
PACIFIC PAIN & JOINT CENTERS
Provider Other Organization Name Type Code:
3
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:
1891033668
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/29/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12672 LIMONITE AVE.
Provider Second Line Business Mailing Address:
SUITE 3E-235
Provider Business Mailing Address City Name:
EASTVALE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92880-4208
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-479-8546
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4024 12TH ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
RIVERSIDE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92501-3561
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-683-0300
Provider Business Practice Location Address Fax Number:
951-683-0310
Provider Enumeration Date:
01/29/2013

Additional Information

Authorized Official

Authorized Official Last Name:
WILBUR
Authorized Official First Name:
BENJAMIN
Authorized Official Middle Name:
STUART
Authorized Official Title or Position:
CEO/PHYSICIAN
Authorized Official Telephone Number:
951-479-8546

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207XX0005X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208VP0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225700000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QP3300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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