1316287246 NPI number — MRS. SHUREE GANGLOFF SMOCK PT, DPT

Table of content: MRS. SHUREE GANGLOFF SMOCK PT, DPT (NPI 1316287246)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316287246 NPI number — MRS. SHUREE GANGLOFF SMOCK PT, DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMOCK
Provider First Name:
SHUREE
Provider Middle Name:
GANGLOFF
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GANGLOFF
Provider Other First Name:
SHUREE
Provider Other Middle Name:
N/A
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT, DPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1316287246
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/12/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 50004
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PASADENA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91115-0004
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-683-8536
Provider Business Mailing Address Fax Number:
626-683-8236

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 E DEL MAR BLVD
Provider Second Line Business Practice Location Address:
SUITE 302
Provider Business Practice Location Address City Name:
PASADENA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91105-2544
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-683-8236
Provider Business Practice Location Address Fax Number:
626-683-8236
Provider Enumeration Date:
03/01/2013

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: 225100000X , with the licence number:  39976 , 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)





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