1376080309 NPI number — INTERNATIONAL PRE-DIABETES CENTER INC

Table of content: (NPI 1376080309)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376080309 NPI number — INTERNATIONAL PRE-DIABETES CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTERNATIONAL PRE-DIABETES CENTER INC
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:
INTERNATIONAL PRE-DIABETES CENTER INC.
Provider Other Organization Name Type Code:
3
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:
1376080309
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/22/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14421 GLORIETTA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHERMAN OAKS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91423-4533
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-714-2066
Provider Business Mailing Address Fax Number:
818-387-6224

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14500 ROSCOE BLVD., 4TH FLOOR
Provider Second Line Business Practice Location Address:
4TH FLOOR
Provider Business Practice Location Address City Name:
PANORAMA CITY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-714-2066
Provider Business Practice Location Address Fax Number:
818-387-6224
Provider Enumeration Date:
01/29/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GRANT
Authorized Official First Name:
YVONNE
Authorized Official Middle Name:
E.
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER (CEO)
Authorized Official Telephone Number:
818-625-6756

Provider Taxonomy Codes

  • Taxonomy code: 163WD0400X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 174H00000X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1835G0303X , with the licence number: 10028 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X , with the licence number: 38828 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251V00000X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X , with the licence number: 38828 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332B00000X , with the licence number: 96123 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 96123 . This is a "DIABETES HOME MEDICAL DEVICE, DEPT. OF PUBLIC HEALTH, FOOD & DRUG BRANCH" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 7658690001 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1376080309 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200913353 . This is a "CERTIFIED DIABETES EDUCATOR" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".