1104859552 NPI number — DR. CARMELO DICHOSA BANTIQUE JR. D.C.

Table of content: DR. CARMELO DICHOSA BANTIQUE JR. D.C. (NPI 1104859552)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104859552 NPI number — DR. CARMELO DICHOSA BANTIQUE JR. D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BANTIQUE
Provider First Name:
CARMELO
Provider Middle Name:
DICHOSA
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
D.C.
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:
1104859552
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/07/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3301 WATT AVE
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
SACRAMENTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95821-3621
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-483-3423
Provider Business Mailing Address Fax Number:
916-483-8555

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3301 WATT AVE
Provider Second Line Business Practice Location Address:
SUITE 400
Provider Business Practice Location Address City Name:
SACRAMENTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95821-3621
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-483-3423
Provider Business Practice Location Address Fax Number:
916-483-8555
Provider Enumeration Date:
07/09/2006

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: 111N00000X , with the licence number:  DC29892 , 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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