1962693762 NPI number — GINA-MARIE CIMMARRUSTI PORTER MFTI, AT

Table of content: GINA-MARIE CIMMARRUSTI PORTER MFTI, AT (NPI 1962693762)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962693762 NPI number — GINA-MARIE CIMMARRUSTI PORTER MFTI, AT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PORTER
Provider First Name:
GINA-MARIE
Provider Middle Name:
CIMMARRUSTI
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MFTI, AT
Provider Gender Code:
F

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:
1962693762
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/25/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
22985 DITZ LN
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:
92630-4112
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-701-0598
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22985 DITZ LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE FOREST
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92630-4112
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-701-0598
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/06/2007

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: 106H00000X , with the licence number:  IMF 57337 , 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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