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

Table of content: NICHOLAS MACHAEL VETRANO M.D. (NPI 1083848808)

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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