1174294060 NPI number — MR. WILLIAM EDWARD FLANNERY SUDCC

Table of content: MR. WILLIAM EDWARD FLANNERY SUDCC (NPI 1174294060)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174294060 NPI number — MR. WILLIAM EDWARD FLANNERY SUDCC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FLANNERY
Provider First Name:
WILLIAM
Provider Middle Name:
EDWARD
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
SUDCC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FLANNERY
Provider Other First Name:
WILLIAM
Provider Other Middle Name:
E
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
SUDCC
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1174294060
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/21/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11975 TEXAS AVE APT 302
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90025-7705
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
925-570-1446
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
905 PICO BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA MONICA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90405-1326
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-314-6200
Provider Business Practice Location Address Fax Number:
310-450-2024
Provider Enumeration Date:
09/21/2021

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: 101YA0400X , with the licence number:  11915 , 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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