1245739820 NPI number — NORTHRIDGE VASCULAR CENTER A PROFESSIONAL MEDICAL CORPORATION

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245739820 NPI number — NORTHRIDGE VASCULAR CENTER A PROFESSIONAL MEDICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHRIDGE VASCULAR CENTER A PROFESSIONAL MEDICAL CORPORATION
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:
1245739820
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/31/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10605 BALBOA BLVD
Provider Second Line Business Mailing Address:
STE 240
Provider Business Mailing Address City Name:
GRANADA HILLS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91344
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
424-241-7160
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19331 BUSINESS CENTER DR STE 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTHRIDGE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91324-3533
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-709-5555
Provider Business Practice Location Address Fax Number:
818-739-1465
Provider Enumeration Date:
02/08/2018

Additional Information

Authorized Official

Authorized Official Last Name:
ASSOMULL
Authorized Official First Name:
VINOD
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
424-241-7160

Provider Taxonomy Codes

  • Taxonomy code: 2085R0204X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2086S0129X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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