1942477997 NPI number — MISS BOGUSLAWA TERESA SYROTIAK

Table of content: MISS BOGUSLAWA TERESA SYROTIAK (NPI 1942477997)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942477997 NPI number — MISS BOGUSLAWA TERESA SYROTIAK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SYROTIAK
Provider First Name:
BOGUSLAWA
Provider Middle Name:
TERESA
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:
KELLOGG
Provider Other First Name:
BOGUSLAWA
Provider Other Middle Name:
TERESA
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
OTR L
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1942477997
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/09/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21802 MICHIGAN LANE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE FOREST
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92630
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-831-8182
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16257 LAGUNA CANYON ROAD
Provider Second Line Business Practice Location Address:
SUITE 150
Provider Business Practice Location Address City Name:
IRVINE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92618
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-727-2192
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/09/2008

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: 225X00000X , with the licence number:  9987 , 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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