1063886166 NPI number — COMPREHENSIVE INFECTIOUS DISEASE CONSULTANTS A MEDICAL CORPORATION

Table of content: REGINA FAYE DAVIS CDCA (NPI 1346749652)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063886166 NPI number — COMPREHENSIVE INFECTIOUS DISEASE CONSULTANTS A MEDICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMPREHENSIVE INFECTIOUS DISEASE CONSULTANTS A MEDICAL CORPORATION
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:
1063886166
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/28/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 572770
Provider Second Line Business Mailing Address:
SUITE 415
Provider Business Mailing Address City Name:
TARZANA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91357-2770
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-506-3384
Provider Business Mailing Address Fax Number:
818-699-1278

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18370 BURBANK BLVD
Provider Second Line Business Practice Location Address:
STE 414
Provider Business Practice Location Address City Name:
TARZANA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91356-2804
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-506-3384
Provider Business Practice Location Address Fax Number:
818-699-1278
Provider Enumeration Date:
11/30/2015

Additional Information

Authorized Official

Authorized Official Last Name:
SHELUB
Authorized Official First Name:
AARON
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
818-506-3384

Provider Taxonomy Codes

  • Taxonomy code: 207RI0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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