1053698134 NPI number — CHARTER HEALTHCARE OF RANCHO CUCAMONGA, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053698134 NPI number — CHARTER HEALTHCARE OF RANCHO CUCAMONGA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHARTER HEALTHCARE OF RANCHO CUCAMONGA, LLC
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:
1053698134
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/20/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9229 UTICA AVE., SUITE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RANCHO CUCAMONGA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91730-4063
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-669-1686
Provider Business Mailing Address Fax Number:
909-532-8685

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9229 UTICA AVE., SUITE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RANCHO CUCAMONGA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91730-4063
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-669-1686
Provider Business Practice Location Address Fax Number:
909-532-8685
Provider Enumeration Date:
11/03/2011

Additional Information

Authorized Official

Authorized Official Last Name:
BOAL
Authorized Official First Name:
SYLVIE
Authorized Official Middle Name:
Authorized Official Title or Position:
ATTORNEY
Authorized Official Telephone Number:
866-669-1686

Provider Taxonomy Codes

  • Taxonomy code: 251G00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 550001908 . This is a "DEPARTMENT OF PUBLIC HEALTH" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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