1285780494 NPI number — SUNKIST MULTISPECIALTY MEDICAL CLINIC, INC

Table of content: (NPI 1285780494)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285780494 NPI number — SUNKIST MULTISPECIALTY MEDICAL CLINIC, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUNKIST MULTISPECIALTY MEDICAL CLINIC, 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:
1285780494
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13909 AMAR RD STE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LA PUENTE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91746-1600
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-960-8887
Provider Business Mailing Address Fax Number:
626-338-0227

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13909 AMAR RD STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA PUENTE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91746-1600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-960-8887
Provider Business Practice Location Address Fax Number:
626-338-0227
Provider Enumeration Date:
01/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
AUERBACH
Authorized Official First Name:
RICK
Authorized Official Middle Name:
JON
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
626-960-8887

Provider Taxonomy Codes

  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: GR0087790 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: G37465 . This is a "MEDICARE RENDERING PHYS" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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