1184902975 NPI number — ICI 24 7 PC

Table of content: (NPI 1184902975)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184902975 NPI number — ICI 24 7 PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ICI 24 7 PC
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:
1184902975
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:
100 BAYVIEW CIR
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
NEWPORT BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92660-2983
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-242-5300
Provider Business Mailing Address Fax Number:
602-345-7733

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3305 CORINTH PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORINTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76208-5380
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
940-270-4100
Provider Business Practice Location Address Fax Number:
602-345-7733
Provider Enumeration Date:
07/27/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BLOOM
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
978-552-2732

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)