1134251192 NPI number — PROHEALTH PARTNERS, A MEDICAL GROUP, INC.

Table of content: (NPI 1134251192)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134251192 NPI number — PROHEALTH PARTNERS, A MEDICAL GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROHEALTH PARTNERS, A MEDICAL GROUP, 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:
1134251192
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/24/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1045 ATLANTIC AVE
Provider Second Line Business Mailing Address:
SUITE 705
Provider Business Mailing Address City Name:
LONG BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90813-3408
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1760 TERMINO AVE STE 214
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONG BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90804-2169
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-595-4718
Provider Business Practice Location Address Fax Number:
562-591-7323
Provider Enumeration Date:
03/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ALLSWANG
Authorized Official First Name:
BARRY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
562-299-5239

Provider Taxonomy Codes

  • Taxonomy code: 207RE0101X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: GR006415A , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZ51266Z . This is a "BLUE SHIELD GROUP NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com