1235570607 NPI number — TRILOGY EYE MEDICAL GROUP, INC.

Table of content: (NPI 1235570607)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235570607 NPI number — TRILOGY EYE MEDICAL GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRILOGY EYE MEDICAL GROUP, INC.
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:
1235570607
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 E CALIFORNIA BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PASADENA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91105-3205
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-269-5371
Provider Business Mailing Address Fax Number:
626-577-2100

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
207 S SANTA ANITA AVE
Provider Second Line Business Practice Location Address:
SUITE P-25
Provider Business Practice Location Address City Name:
SAN GABRIEL
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91776-1146
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-269-5355
Provider Business Practice Location Address Fax Number:
626-284-8448
Provider Enumeration Date:
07/12/2013

Additional Information

Authorized Official

Authorized Official Last Name:
CHANG
Authorized Official First Name:
TOM
Authorized Official Middle Name:
S
Authorized Official Title or Position:
FOUNDER/OWNER
Authorized Official Telephone Number:
626-289-2223

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207WX0107X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 174400000X , 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: FQ161A . This is a "MCR(S)" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: FQ161B . This is a "MCR(N)" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1114205432 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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