1275885113 NPI number — MR. MICHAEL WAYNE BETTIS

Table of content: MR. MICHAEL WAYNE BETTIS (NPI 1275885113)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275885113 NPI number — MR. MICHAEL WAYNE BETTIS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BETTIS
Provider First Name:
MICHAEL
Provider Middle Name:
WAYNE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
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:
1275885113
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/08/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4286 STONEBRIAR CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORONA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92883-0671
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-415-9367
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
850 E FOOTHILL BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIALTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92376-5230
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-580-2141
Provider Business Practice Location Address Fax Number:
909-580-2866
Provider Enumeration Date:
10/02/2012

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: 106H00000X , with the licence number:  76826 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 106H00000X , with the licence number: 117278 , 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: 117278 . This is a "BBS" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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