1225471956 NPI number — MLT KIDANE PHYSICIAN ASSISTANT CORPORATION

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 1225471956 NPI number — MLT KIDANE PHYSICIAN ASSISTANT CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MLT KIDANE PHYSICIAN ASSISTANT CORPORATION
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:
1225471956
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/11/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12981 PERRIS BLVD
Provider Second Line Business Mailing Address:
SUITE #101
Provider Business Mailing Address City Name:
MORENO VALLEY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92553-4102
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-571-0632
Provider Business Mailing Address Fax Number:
951-571-4149

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12981 PERRIS BLVD
Provider Second Line Business Practice Location Address:
SUITE #101
Provider Business Practice Location Address City Name:
MORENO VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92553-4102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-571-0632
Provider Business Practice Location Address Fax Number:
951-571-4149
Provider Enumeration Date:
04/11/2013

Additional Information

Authorized Official

Authorized Official Last Name:
KIDANE
Authorized Official First Name:
MEAZA
Authorized Official Middle Name:
Z.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
951-571-0632

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  PA20768 , 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)





Copyright © 2007-2025 www.npivalidator.com