1235353061 NPI number — MR. DOUGLAS JOEL FENDRICH BC HIS

Table of content: MR. DOUGLAS JOEL FENDRICH BC HIS (NPI 1235353061)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235353061 NPI number — MR. DOUGLAS JOEL FENDRICH BC HIS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FENDRICH
Provider First Name:
DOUGLAS
Provider Middle Name:
JOEL
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
BC HIS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FENDRICH
Provider Other First Name:
DOUG
Provider Other Middle Name:
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1235353061
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13112 E HADLEY ST
Provider Second Line Business Mailing Address:
SUITE 108
Provider Business Mailing Address City Name:
WHITTIER
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90601-4583
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
562-696-5054
Provider Business Mailing Address Fax Number:
562-696-5054

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13112 E HADLEY ST
Provider Second Line Business Practice Location Address:
SUITE 108
Provider Business Practice Location Address City Name:
WHITTIER
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90601-4583
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-696-5054
Provider Business Practice Location Address Fax Number:
562-696-5054
Provider Enumeration Date:
04/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 237700000X , with the licence number:  HA2291 , 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: HA2291 . This is a "INSURANCE FORMS" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: HAOO22910 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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