1063434900 NPI number — SOMA MEDICAL GROUP

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 1063434900 NPI number — SOMA MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOMA MEDICAL GROUP
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:
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:
1063434900
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/04/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5090
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
REDONDO BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90278-9290
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-214-1000
Provider Business Mailing Address Fax Number:
310-214-8540

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1959 KINGSDALE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
REDONDO BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90278-3417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-214-1000
Provider Business Practice Location Address Fax Number:
310-214-8540
Provider Enumeration Date:
07/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DAVOUDIAN
Authorized Official First Name:
SOHAIL
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
310-214-1000

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  A44878 , 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: GR0059090 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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