1215991278 NPI number — SAN FERNANDO MISSION MEDICAL GRP

Table of content: (NPI 1215991278)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215991278 NPI number — SAN FERNANDO MISSION MEDICAL GRP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAN FERNANDO MISSION MEDICAL GRP
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:
6
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:
1215991278
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/19/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8215 VAN NUYS BLVD
Provider Second Line Business Mailing Address:
210-204
Provider Business Mailing Address City Name:
PANORAMA CITY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91402-4810
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-782-4325
Provider Business Mailing Address Fax Number:
818-782-7320

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8215 VAN NUYS BLVD
Provider Second Line Business Practice Location Address:
210-204
Provider Business Practice Location Address City Name:
PANORAMA CITY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91402-4810
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-782-4325
Provider Business Practice Location Address Fax Number:
818-782-7320
Provider Enumeration Date:
04/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GREY
Authorized Official First Name:
ERLINDA
Authorized Official Middle Name:
DY
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
818-782-4325

Provider Taxonomy Codes

  • Taxonomy code: 170100000X , with the licence number:  A30427 , 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: GR0059210 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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