1407063837 NPI number — LAWRENCE CHESPAK, APC

Table of content: (NPI 1407063837)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407063837 NPI number — LAWRENCE CHESPAK, APC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAWRENCE CHESPAK, APC
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:
1407063837
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/10/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5554 RESEDA BLVD
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
TARZANA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91356-2200
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-707-7704
Provider Business Mailing Address Fax Number:
818-708-7707

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5554 RESEDA BLVD
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
TARZANA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91356-2200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-707-7704
Provider Business Practice Location Address Fax Number:
818-708-7707
Provider Enumeration Date:
05/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CHESPAK
Authorized Official First Name:
LAWRENCE
Authorized Official Middle Name:
WALTER
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
818-707-7704

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  G62697 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 235Z00000X , with the licence number: CCC9644 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: ZZZ67240Z . This is a "BLUE SHIELD PROVIDER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: CCC9644 . This is a "SLP LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 704362 . This is a "ACN PROVIDER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: G62697 . This is a "LICENSE NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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