1164196457 NPI number — GARRY ROGER DORMEVIL NURSE PRACTITIONER

Table of content: GARRY ROGER DORMEVIL NURSE PRACTITIONER (NPI 1164196457)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164196457 NPI number — GARRY ROGER DORMEVIL NURSE PRACTITIONER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DORMEVIL
Provider First Name:
GARRY
Provider Middle Name:
ROGER
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NURSE PRACTITIONER
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:
1164196457
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/07/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
135 S STATE COLLEGE BLVD STE 350
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BREA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92821-5814
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-719-3700
Provider Business Mailing Address Fax Number:
805-413-9099

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
79440 CORPORATE CENTER DR STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA QUINTA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92253-7243
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-719-3700
Provider Business Practice Location Address Fax Number:
805-413-9099
Provider Enumeration Date:
08/02/2021

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: 363LF0000X , with the licence number:  0024180743 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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