1184841769 NPI number — MRS. DESIREE FAJAYAN BRADFORD MOTR

Table of content: MRS. DESIREE FAJAYAN BRADFORD MOTR (NPI 1184841769)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184841769 NPI number — MRS. DESIREE FAJAYAN BRADFORD MOTR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRADFORD
Provider First Name:
DESIREE
Provider Middle Name:
FAJAYAN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MOTR
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FAJAYAN
Provider Other First Name:
DEISREE
Provider Other Middle Name:
FLOREZA
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1184841769
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/02/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1627 HADAR WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEAUMONT
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92223-6119
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-310-8367
Provider Business Mailing Address Fax Number:
951-769-2502

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1627 HADAR WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEAUMONT
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92223-6119
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-310-8367
Provider Business Practice Location Address Fax Number:
951-769-2502
Provider Enumeration Date:
04/18/2007

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: 225X00000X , with the licence number:  8535 , 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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