1114288065 NPI number — MRS. JANE CHRISTABELLE PODREBARAC MPT

Table of content: MRS. JANE CHRISTABELLE PODREBARAC MPT (NPI 1114288065)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114288065 NPI number — MRS. JANE CHRISTABELLE PODREBARAC MPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PODREBARAC
Provider First Name:
JANE
Provider Middle Name:
CHRISTABELLE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TAYLOR
Provider Other First Name:
JANE
Provider Other Middle Name:
CHRISTABELLE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1114288065
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/06/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
79 E HIGHLAND AVE
Provider Second Line Business Mailing Address:
APT. D
Provider Business Mailing Address City Name:
SIERRA MADRE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91024-1945
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-836-3129
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
79 E HIGHLAND AVE
Provider Second Line Business Practice Location Address:
APT. D
Provider Business Practice Location Address City Name:
SIERRA MADRE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91024-1945
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-836-3129
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/06/2012

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: 225100000X , with the licence number:  23464 , 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)





Copyright © 2007-2025 www.npivalidator.com