1174801054 NPI number — RUCKER MEDICAL GROUP INC

Table of content: (NPI 1174801054)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174801054 NPI number — RUCKER MEDICAL GROUP INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RUCKER MEDICAL GROUP 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:
1174801054
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/27/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5265 FOUNTAIN AVE
Provider Second Line Business Mailing Address:
SUITE 1A
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90029-1300
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
323-662-7764
Provider Business Mailing Address Fax Number:
323-662-7714

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5265 FOUNTAIN AVE
Provider Second Line Business Practice Location Address:
SUITE 1A
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90029-1300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-662-7764
Provider Business Practice Location Address Fax Number:
323-662-7714
Provider Enumeration Date:
07/27/2011

Additional Information

Authorized Official

Authorized Official Last Name:
RUCKER
Authorized Official First Name:
BURNETT
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
323-662-7764

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  A34349 , 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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