1164554713 NPI number — LEO NYHOLM

Table of content: (NPI 1164554713)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164554713 NPI number — LEO NYHOLM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LEO NYHOLM
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:
6
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:
1164554713
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/18/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20825 SOUTH ST
Provider Second Line Business Mailing Address:
SUITE D
Provider Business Mailing Address City Name:
TEHACHAPI
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93561-8649
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
661-822-1965
Provider Business Mailing Address Fax Number:
661-823-1971

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20825 SOUTH ST
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
TEHACHAPI
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93561-8649
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
661-822-1965
Provider Business Practice Location Address Fax Number:
661-823-1971
Provider Enumeration Date:
03/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
NYHOLM
Authorized Official First Name:
LEO
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
661-822-1965

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  CLF 11592 , 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: ZZZ17938Z . This is a "MEDICARE PTAN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 05D0962446 . This is a "CLIA NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: CLF11592 . This is a "LABORATORY LICENSE NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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