1356588123 NPI number — QUEEN MARY DAVIS REGISTERED NURSE

Table of content: QUEEN MARY DAVIS REGISTERED NURSE (NPI 1356588123)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356588123 NPI number — QUEEN MARY DAVIS REGISTERED NURSE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVIS
Provider First Name:
QUEEN
Provider Middle Name:
MARY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
REGISTERED NURSE
Provider Gender Code:
F

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:
1356588123
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/14/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1807 S GENESEE AVE
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:
90019-5032
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
323-933-9014
Provider Business Mailing Address Fax Number:
323-937-1872

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1807 S GENESEE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90019-5032
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-933-9014
Provider Business Practice Location Address Fax Number:
323-937-1872
Provider Enumeration Date:
01/14/2009

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: 172A00000X , with the licence number:  CA #0367076 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 172V00000X , with the licence number: CA# 0367076 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: NAICS 624120 . This is a "SERVICE FOR ELDERLY AND PERSONS WITH DISABILITIES" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: CA# 0367076 . This is a "DEPARTMENT OF MOTOR VEHICLES- MOTOR CARRIER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 0055719 . This is a "CALIFORNIA SMALL BUSINESS CERTIFICATION" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0055719 . This is a "REGISTERED LOS ANGELES COUNTY VENDOR" identifier . This identifiers is of the category "OTHER".
  • Identifier: SIC 8322 . This is a "INDIVIDUAL & FAMILY SOCIAL SERVICE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 20080702766 . This is a "FICTITIOUS BUSINESS NAME STATEMENT" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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