1407858178 NPI number — KEVEN TAGDIRI, MD, INC.

Table of content: JASON EMMANUEL CARR MA, MFT (NPI 1447553375)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407858178 NPI number — KEVEN TAGDIRI, MD, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KEVEN TAGDIRI, MD, INC.
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:
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:
1407858178
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/25/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4401 MANCHESTER AVE
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
ENCINITAS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92024-4938
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-756-3021
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4401 MANCHESTER AVE
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
ENCINITAS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92024-4938
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-756-3021
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/12/2005

Additional Information

Authorized Official

Authorized Official Last Name:
TAGDIRI
Authorized Official First Name:
KEVEN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
858-756-3021

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  01596 , 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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