1093221830 NPI number — MARIA CLARISA LUKEN RASCON

Table of content: (NPI 1093221830)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093221830 NPI number — MARIA CLARISA LUKEN RASCON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARIA CLARISA LUKEN RASCON
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:
1093221830
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/15/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4275 EXECUTIVE SQUARE
Provider Second Line Business Mailing Address:
STE 200
Provider Business Mailing Address City Name:
LA JOLLA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92037-9123
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-488-3200
Provider Business Mailing Address Fax Number:
866-272-6924

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
AV. A. NUM 235
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALGODONES
Provider Business Practice Location Address State Name:
B.C.
Provider Business Practice Location Address Postal Code:
21970
Provider Business Practice Location Address Country Code:
MX
Provider Business Practice Location Address Telephone Number:
669-992-8700
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/15/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LUKEN RASCON
Authorized Official First Name:
MARIA
Authorized Official Middle Name:
CLARISA
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
619-488-3200

Provider Taxonomy Codes

  • Taxonomy code: 1223P0300X , with the licence number:  7953115 , registered in the state of ZZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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