1295107753 NPI number — ADVANCED GROWTH, INC

Table of content: (NPI 1295107753)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295107753 NPI number — ADVANCED GROWTH, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED GROWTH, 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:
1295107753
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/23/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 910913
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90091-0913
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-549-8884
Provider Business Mailing Address Fax Number:
888-751-6166

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19W706 13TH PL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOMBARD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60148-4505
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-948-9998
Provider Business Practice Location Address Fax Number:
888-776-8838
Provider Enumeration Date:
10/23/2015

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MA
Authorized Official First Name:
SIEU
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF OPERATION
Authorized Official Telephone Number:
888-549-8884

Provider Taxonomy Codes

  • Taxonomy code: 323P00000X , with the licence number:  533073-01 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 324500000X , with the licence number: 533073-01 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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