1114084092 NPI number — GUIAMELON MEDICAL CLINIC, INC.

Table of content: MITCHELL C KUPPINGER MD (NPI 1174517809)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114084092 NPI number — GUIAMELON MEDICAL CLINIC, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GUIAMELON MEDICAL CLINIC, INC.
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:
1114084092
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/04/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6130 BONNER AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH HOLLYWOOD
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91606-4918
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-980-6749
Provider Business Mailing Address Fax Number:
818-980-6749

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7301 SEPULVEDA BLVD
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
VAN NUYS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91405-1782
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-786-7710
Provider Business Practice Location Address Fax Number:
818-786-7711
Provider Enumeration Date:
01/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GUIAMELON
Authorized Official First Name:
RITA
Authorized Official Middle Name:
PARAISO
Authorized Official Title or Position:
PRESIDENT AND MEDICAL DIRECTOR
Authorized Official Telephone Number:
818-426-0649

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  A84265 , 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: A84265 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 232930 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00A842650 . This is a "MEDI-CAL PROVIDER NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 025209 MD00040515 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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