1255648705 NPI number — MR. EDWARD APOLINARIO QUINTOS PTA

Table of content: MR. EDWARD APOLINARIO QUINTOS PTA (NPI 1255648705)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255648705 NPI number — MR. EDWARD APOLINARIO QUINTOS PTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
QUINTOS
Provider First Name:
EDWARD
Provider Middle Name:
APOLINARIO
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PTA
Provider Gender Code:
M

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:
1255648705
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/03/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4406 EARLE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROSEMEAD
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91770-1154
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-487-7062
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1313 W 8TH ST
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90017-4420
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-401-1985
Provider Business Practice Location Address Fax Number:
213-401-1987
Provider Enumeration Date:
09/03/2010

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: 225200000X , with the licence number:  8653 , 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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