1407047673 NPI number — VERICARE OF CALIFORNIA MEDICAL GROUP

Table of content: (NPI 1407047673)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407047673 NPI number — VERICARE OF CALIFORNIA MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VERICARE OF CALIFORNIA MEDICAL GROUP
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:
1407047673
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/11/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
55 HATCHETTS HILL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OLD LTME
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06371-1534
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-370-3651
Provider Business Mailing Address Fax Number:
877-515-7147

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3293 N DRINKWATER BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SCOTTSDALE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85251-6405
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-947-7443
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/05/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KING
Authorized Official First Name:
MELISSA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR, CREDENTIALING ENROLLMENT
Authorized Official Telephone Number:
800-370-3652

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0808X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 364SP0808X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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