1013079177 NPI number — FAIRMONT HEALTHCARE CORP.

Table of content: (NPI 1013079177)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013079177 NPI number — FAIRMONT HEALTHCARE CORP.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAIRMONT HEALTHCARE CORP.
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:
6
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:
1013079177
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13907 AMAR RD
Provider Second Line Business Mailing Address:
UNIT D
Provider Business Mailing Address City Name:
LA PUENTE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91746-1676
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-338-4606
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13907 E. AMAR RD
Provider Second Line Business Practice Location Address:
UNIT D
Provider Business Practice Location Address City Name:
LA PUENTE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91746-1676
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-338-4606
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DEVERA
Authorized Official First Name:
SHIRLEY
Authorized Official Middle Name:
S
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
626-338-4606

Provider Taxonomy Codes

  • Taxonomy code: 261QA0600X , 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)

  • Identifier: ADU70167G . This is a "PROVIDER NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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