1174808893 NPI number — CECILIA CALDERON

Table of content: CECILIA CALDERON (NPI 1174808893)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174808893 NPI number — CECILIA CALDERON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CALDERON
Provider First Name:
CECILIA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

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:
1174808893
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/27/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4760 SEPULVEDA BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CULVER CITY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90230-4820
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-390-6612
Provider Business Mailing Address Fax Number:
310-398-5690

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12420 VENICE BLVD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90066-3840
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-751-1200
Provider Business Practice Location Address Fax Number:
310-398-0312
Provider Enumeration Date:
10/13/2011

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: 106H00000X , with the licence number:  104751 , 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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