1235202961 NPI number — RAI CARE CENTERS OF SOUTHERN CALIFORNIA I, LLC

Table of content: (NPI 1235202961)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235202961 NPI number — RAI CARE CENTERS OF SOUTHERN CALIFORNIA I, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RAI CARE CENTERS OF SOUTHERN CALIFORNIA I, LLC
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:
1235202961
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/27/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12555 GARDEN GROVE BLVD
Provider Second Line Business Mailing Address:
SUITE100
Provider Business Mailing Address City Name:
GARDEN GROVE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92843-1902
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-741-7255
Provider Business Mailing Address Fax Number:
714-741-2029

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12555 GARDEN GROVE BLVD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
GARDEN GROVE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92843-1902
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-741-7255
Provider Business Practice Location Address Fax Number:
714-741-2029
Provider Enumeration Date:
11/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FAWCETT
Authorized Official First Name:
MARK
Authorized Official Middle Name:
R
Authorized Official Title or Position:
TREASURER
Authorized Official Telephone Number:
781-699-9000

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 052617 . This is a "BLUE CROSS OF CALIFORNIA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: CDC02617G , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZR0209Z . This is a "BLUE SHIELD OF CALIFORNIA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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