1194822320 NPI number — METRO-MED, INC. - LOS ALAMITOS

Table of content: (NPI 1194822320)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194822320 NPI number — METRO-MED, INC. - LOS ALAMITOS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
METRO-MED, INC. - LOS ALAMITOS
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:
1194822320
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/15/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8999 GEMINI PKWY STE 220
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBUS
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43240-2250
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
614-573-9075
Provider Business Mailing Address Fax Number:
614-568-5290

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10841 NOEL ST
Provider Second Line Business Practice Location Address:
STE. 108, 103
Provider Business Practice Location Address City Name:
LOS ALAMITOS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90720-2597
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-761-9761
Provider Business Practice Location Address Fax Number:
714-761-8455
Provider Enumeration Date:
09/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
YAEGER
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
818-840-9090

Provider Taxonomy Codes

  • Taxonomy code: 332BX2000X , with the licence number:  100347 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X , with the licence number: 100347 , 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: DME03175F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZ133182 . This is a "BLUE SHIELD PROVIDER #" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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