1245392554 NPI number — SAN CRISTOBAL MEDICAL GROUP INC

Table of content: (NPI 1245392554)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245392554 NPI number — SAN CRISTOBAL MEDICAL GROUP INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAN CRISTOBAL 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:
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:
1245392554
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1930 WILSHIRE BLVD
Provider Second Line Business Mailing Address:
SUITE 410
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90057-3605
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
213-413-4203
Provider Business Mailing Address Fax Number:
213-413-5615

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2011 W WHITTIER BLVD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
MONTEBELLO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90640-4010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-838-5994
Provider Business Practice Location Address Fax Number:
323-838-0779
Provider Enumeration Date:
12/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HRABKO
Authorized Official First Name:
RANDALL
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
213-413-4203

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X , with the licence number:  G39326 , 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)





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