1235180951 NPI number — LYONS & POPPLE MEDICAL CORP

Table of content: (NPI 1235180951)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235180951 NPI number — LYONS & POPPLE MEDICAL CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LYONS & POPPLE MEDICAL CORP
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:
1235180951
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/02/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 7096
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STOCKTON
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95267
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-956-7725
Provider Business Mailing Address Fax Number:
209-956-7733

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
650 SANITARIUM
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DEER PARK
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94576
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-963-3611
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LYONS
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
Authorized Official Title or Position:
GROUP PRESIDENT
Authorized Official Telephone Number:
707-963-3611

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: ZZZ03794Z . This is a "BS OF CA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0092420 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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