1891072914 NPI number — MISS KAREN TIRADOR PENAREDONDO

Table of content: MISS KAREN TIRADOR PENAREDONDO (NPI 1891072914)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891072914 NPI number — MISS KAREN TIRADOR PENAREDONDO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PENAREDONDO
Provider First Name:
KAREN
Provider Middle Name:
TIRADOR
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PENAREDONDO
Provider Other First Name:
KAREN
Provider Other Middle Name:
TIRADOR
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1891072914
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/03/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10950 CABRILLO LOOP
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOMA LINDA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92354-2236
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-653-3291
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1350 RECHE CANYON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLTON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92324-9528
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-370-4411
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/03/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  35036 , 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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