1205378536 NPI number — MEDEVALS OF CALIFORNIA, P.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205378536 NPI number — MEDEVALS OF CALIFORNIA, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDEVALS OF CALIFORNIA, P.C.
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:
1205378536
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/28/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
536 BLUEBIRD CANYON DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAGUNA BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92651-3307
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-510-2810
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2280 DIAMOND BLVD
Provider Second Line Business Practice Location Address:
#570
Provider Business Practice Location Address City Name:
CONCORD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94520-5750
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
925-682-1951
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/17/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
NAHM
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
A
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
949-510-2810

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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