1265617823 NPI number — GRANCELL VILLAGE OF THE LOS ANGELES

Table of content: (NPI 1265617823)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265617823 NPI number — GRANCELL VILLAGE OF THE LOS ANGELES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRANCELL VILLAGE OF THE LOS ANGELES
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:
1265617823
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/25/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7150 TAMPA AVE
Provider Second Line Business Mailing Address:
1ST FLOOR
Provider Business Mailing Address City Name:
RESEDA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91335-3700
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-758-5017
Provider Business Mailing Address Fax Number:
818-774-2430

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7150 TAMPA AVE
Provider Second Line Business Practice Location Address:
1ST FLOOR
Provider Business Practice Location Address City Name:
RESEDA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91335
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-758-5017
Provider Business Practice Location Address Fax Number:
818-774-2430
Provider Enumeration Date:
01/02/2008

Additional Information

Authorized Official

Authorized Official Last Name:
SHMAEFF
Authorized Official First Name:
BOB
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF PHARMACY SERVICES
Authorized Official Telephone Number:
818-654-5521

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336L0003X , with the licence number: MSP48566 , 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: 2113017 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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