1063858058 NPI number — CARDIOVASCULAR ASSOCIATES OF SANTA CRUZ

Table of content: (NPI 1063858058)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063858058 NPI number — CARDIOVASCULAR ASSOCIATES OF SANTA CRUZ

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CARDIOVASCULAR ASSOCIATES OF SANTA CRUZ
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:
1063858058
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/05/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1595 SOQUEL DRIVE
Provider Second Line Business Mailing Address:
SUITE 220
Provider Business Mailing Address City Name:
SANTA CRUZ
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95065-1560
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
831-464-3801
Provider Business Mailing Address Fax Number:
831-464-2737

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1595 SOQUEL DRIVE
Provider Second Line Business Practice Location Address:
SUITE 220
Provider Business Practice Location Address City Name:
SANTA CRUZ
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95065-1560
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
831-464-3801
Provider Business Practice Location Address Fax Number:
831-464-2737
Provider Enumeration Date:
05/16/2013

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
JAY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER/PARTNER
Authorized Official Telephone Number:
831-334-2316

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  G73261 , 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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