1164777090 NPI number — OAC SOUTHERN MEDICAL PROFESSIONAL CORPORATION

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164777090 NPI number — OAC SOUTHERN MEDICAL PROFESSIONAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OAC SOUTHERN MEDICAL PROFESSIONAL CORPORATION
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:
1164777090
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/17/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
23430 HAWTHORNE BLVD
Provider Second Line Business Mailing Address:
SUITE 125
Provider Business Mailing Address City Name:
TORRANCE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90505-4720
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-373-0555
Provider Business Mailing Address Fax Number:
310-373-5655

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3300 W COAST HWY
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
NEWPORT BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92663-4007
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-209-0220
Provider Business Practice Location Address Fax Number:
949-270-5139
Provider Enumeration Date:
07/17/2012

Additional Information

Authorized Official

Authorized Official Last Name:
RAHIMI
Authorized Official First Name:
MARYAM
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
310-634-1146

Provider Taxonomy Codes

  • Taxonomy code: 2081S0010X , with the licence number:  20A10143 , 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)





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