1124663455 NPI number — PHYSICIAN AT HOME INC

Table of content: (NPI 1124663455)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124663455 NPI number — PHYSICIAN AT HOME INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHYSICIAN AT HOME 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:
1124663455
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/20/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5907 CERRITOS AVE UNIT 2325
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CYPRESS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90630-8716
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-799-5858
Provider Business Mailing Address Fax Number:
714-799-7272

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7923 GARDEN GROVE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GARDEN GROVE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92841-4225
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-596-0368
Provider Business Practice Location Address Fax Number:
714-591-8265
Provider Enumeration Date:
11/11/2019

Additional Information

Authorized Official

Authorized Official Last Name:
TRAN
Authorized Official First Name:
VU
Authorized Official Middle Name:
D
Authorized Official Title or Position:
MD/PRESIDENT
Authorized Official Telephone Number:
714-496-4207

Provider Taxonomy Codes

  • Taxonomy code: 261QU0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: A138753 . This is a "LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com