1386009108 NPI number — 1125 SIR FRANCIS DRAKE BOULEVARD OPERATING COMPANY, LLC

Table of content: (NPI 1386009108)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386009108 NPI number — 1125 SIR FRANCIS DRAKE BOULEVARD OPERATING COMPANY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
1125 SIR FRANCIS DRAKE BOULEVARD OPERATING COMPANY, LLC
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:
1386009108
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
700 17TH ST STE 205
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MODESTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95354-1249
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-287-6308
Provider Business Mailing Address Fax Number:
209-248-7825

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
450 STANYAN ST
Provider Second Line Business Practice Location Address:
6TH FLOOR
Provider Business Practice Location Address City Name:
SAN FRANCISCO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94117-1019
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
415-456-9680
Provider Business Practice Location Address Fax Number:
415-688-3202
Provider Enumeration Date:
12/21/2015

Additional Information

Authorized Official

Authorized Official Last Name:
THOMPSON
Authorized Official First Name:
TAMMY
Authorized Official Middle Name:
JEAN
Authorized Official Title or Position:
CFO/VP
Authorized Official Telephone Number:
209-287-6308

Provider Taxonomy Codes

  • Taxonomy code: 282E00000X , 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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