1316172323 NPI number — SUPERIOR MULTI-SPECIALTY MEDICAL GROUP INC OF CA

Table of content: (NPI 1316172323)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316172323 NPI number — SUPERIOR MULTI-SPECIALTY MEDICAL GROUP INC OF CA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUPERIOR MULTI-SPECIALTY MEDICAL GROUP INC OF CA
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:
1316172323
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/09/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10808 FOOTHILL BLVD
Provider Second Line Business Mailing Address:
SUITE 160-511
Provider Business Mailing Address City Name:
RANCHO CUCAMONGA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91730-3889
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-989-6469
Provider Business Mailing Address Fax Number:
909-989-6469

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8645 HAVEN AVE
Provider Second Line Business Practice Location Address:
SUITE#700
Provider Business Practice Location Address City Name:
RANCHO CUCAMONGA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91730-4818
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-989-6469
Provider Business Practice Location Address Fax Number:
909-989-6469
Provider Enumeration Date:
05/19/2009

Additional Information

Authorized Official

Authorized Official Last Name:
AMIRNOVIN
Authorized Official First Name:
RAMIN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/DIRECTOR
Authorized Official Telephone Number:
909-989-6469

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  A98619 , 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: 1497736334 . This is a "NPI NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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