1013093103 NPI number — LAJEAN AVON FORBES CNM

Table of content: LAJEAN AVON FORBES CNM (NPI 1013093103)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013093103 NPI number — LAJEAN AVON FORBES CNM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FORBES
Provider First Name:
LAJEAN
Provider Middle Name:
AVON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CNM
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:
1013093103
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1621 VALLEY FALLS AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
REDLANDS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92374-2777
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-794-3411
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12712 HEACOCK ST
Provider Second Line Business Practice Location Address:
SUITE 7
Provider Business Practice Location Address City Name:
MORENO VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92553-3037
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-924-6824
Provider Business Practice Location Address Fax Number:
951-601-9302
Provider Enumeration Date:
10/31/2006

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: 363LX0001X , with the licence number:  CNM 1458 , 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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