1407029069 NPI number — DR. JOHN KEITH NYLUND MD

Table of content: DR. JOHN KEITH NYLUND MD (NPI 1407029069)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407029069 NPI number — DR. JOHN KEITH NYLUND MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NYLUND
Provider First Name:
JOHN
Provider Middle Name:
KEITH
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1407029069
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/25/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14650 AVIATION BLVD
Provider Second Line Business Mailing Address:
SUITE 235
Provider Business Mailing Address City Name:
HAWTHORNE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90250-6668
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-643-9333
Provider Business Mailing Address Fax Number:
310-643-9337

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14650 AVIATION BLVD
Provider Second Line Business Practice Location Address:
SUITE 235
Provider Business Practice Location Address City Name:
HAWTHORNE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90250-6656
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-643-9333
Provider Business Practice Location Address Fax Number:
310-643-9337
Provider Enumeration Date:
04/03/2008

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: 207N00000X , with the licence number:  CO34111 , 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)

  • Identifier: WWH7CB . This is a "PASSWORD FOR PALMETTO" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: CO34111 . This is a "STATE MEDICAL LISCECE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: W9243 . This is a "PPTAN #" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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