1407182876 NPI number — GRACE DIANE PEREZ PSC PARENT PARTNER

Table of content: GRACE DIANE PEREZ PSC PARENT PARTNER (NPI 1407182876)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407182876 NPI number — GRACE DIANE PEREZ PSC PARENT PARTNER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PEREZ
Provider First Name:
GRACE
Provider Middle Name:
DIANE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PSC PARENT PARTNER
Provider Gender Code:
F

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:
1407182876
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/19/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1218 E CLEVELAND AVE
Provider Second Line Business Mailing Address:
SPACE 183
Provider Business Mailing Address City Name:
MADERA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93638-2269
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
559-776-5556
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
83 E SHAW AVE
Provider Second Line Business Practice Location Address:
SUITE #102
Provider Business Practice Location Address City Name:
FRESNO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93710-7620
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-226-0167
Provider Business Practice Location Address Fax Number:
559-226-1559
Provider Enumeration Date:
10/20/2009

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: 171M00000X , 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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