1174679583 NPI number — MISSION PROVIDER SERVICES, INC.

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 1174679583 NPI number — MISSION PROVIDER SERVICES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MISSION PROVIDER SERVICES, 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:
1174679583
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2970 INNSBRUCK DR STE C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
REDDING
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
96003-9303
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
530-222-5633
Provider Business Mailing Address Fax Number:
530-222-5528

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1916 HERBSCENTA LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
REDDING
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96003-1135
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-242-6709
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
EMERSON
Authorized Official First Name:
DANA
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
530-222-5633

Provider Taxonomy Codes

  • Taxonomy code: 315P00000X , 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: 55G198 . This is a "DHS ID NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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