1073051181 NPI number — THEODORE JAVELOSA CELESTE BCTMB

Table of content: THEODORE JAVELOSA CELESTE BCTMB (NPI 1073051181)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073051181 NPI number — THEODORE JAVELOSA CELESTE BCTMB

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CELESTE
Provider First Name:
THEODORE
Provider Middle Name:
JAVELOSA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
BCTMB
Provider Gender Code:
M

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:
1073051181
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/09/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9727 ELK GROVE FLORIN RD
Provider Second Line Business Mailing Address:
SUITE 290
Provider Business Mailing Address City Name:
ELK GROVE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95624-2264
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-685-0818
Provider Business Mailing Address Fax Number:
916-422-8068

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9727 ELK GROVE FLORIN RD
Provider Second Line Business Practice Location Address:
SUITE 290
Provider Business Practice Location Address City Name:
ELK GROVE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95624-2264
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-685-0818
Provider Business Practice Location Address Fax Number:
916-422-8068
Provider Enumeration Date:
02/09/2017

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: 225700000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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