1366447781 NPI number — HOLLENBERG AGRAWAL KNOLL WARREN HONG FUNG TILLIS KAUSHAL MDS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366447781 NPI number — HOLLENBERG AGRAWAL KNOLL WARREN HONG FUNG TILLIS KAUSHAL MDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HOLLENBERG AGRAWAL KNOLL WARREN HONG FUNG TILLIS KAUSHAL MDS
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:
1366447781
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/30/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
250 W BONITA AVE
Provider Second Line Business Mailing Address:
#200
Provider Business Mailing Address City Name:
POMONA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91767-1850
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-620-1935
Provider Business Mailing Address Fax Number:
909-865-7688

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
250 W BONITA AVE
Provider Second Line Business Practice Location Address:
#200
Provider Business Practice Location Address City Name:
POMONA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91767-1850
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-620-1935
Provider Business Practice Location Address Fax Number:
909-865-7688
Provider Enumeration Date:
06/14/2005

Additional Information

Authorized Official

Authorized Official Last Name:
HOLLENBERG
Authorized Official First Name:
JIM
Authorized Official Middle Name:
Authorized Official Title or Position:
STAFF/IT
Authorized Official Telephone Number:
909-620-1935

Provider Taxonomy Codes

  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: GR0066720 . This is a "MEDI CAL GROUP NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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