1104196120 NPI number — JAMIE MEILY HESS N.P.

Table of content: JAMIE MEILY HESS N.P. (NPI 1104196120)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104196120 NPI number — JAMIE MEILY HESS N.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HESS
Provider First Name:
JAMIE
Provider Middle Name:
MEILY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
N.P.
Provider Gender Code:
F

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:
1104196120
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/03/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
393 E WALNUT ST
Provider Second Line Business Mailing Address:
GROUP PROVIDER ENROLLMENT UNIT 3RD FL
Provider Business Mailing Address City Name:
PASADENA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91188-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-608-0044
Provider Business Mailing Address Fax Number:
877-514-0903

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
341 MAGNOLIA AVE
Provider Second Line Business Practice Location Address:
# 201
Provider Business Practice Location Address City Name:
CORONA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92879-3330
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-735-6969
Provider Business Practice Location Address Fax Number:
951-343-3483
Provider Enumeration Date:
01/06/2012

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: 363LW0102X , with the licence number:  21297 , 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: 1104196120 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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