1316669583 NPI number — CRYSTAL MARLENE FALCON SOLE PROPRIETOR

Table of content: CRYSTAL MARLENE FALCON SOLE PROPRIETOR (NPI 1316669583)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316669583 NPI number — CRYSTAL MARLENE FALCON SOLE PROPRIETOR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FALCON
Provider First Name:
CRYSTAL
Provider Middle Name:
MARLENE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
SOLE PROPRIETOR
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LOZOYA
Provider Other First Name:
CRYSTAL
Provider Other Middle Name:
MARLENE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
SOLE PROPRIETOR
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1316669583
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/14/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
26080 BASE LINE ST APT W183
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN BERNARDINO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92410-6115
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-559-4262
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
26080 BASE LINE ST APT W183
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN BERNARDINO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92410-6115
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-559-4262
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/14/2022

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: 106S00000X , with the licence number:  D6348486 , 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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