1417076563 NPI number — ROBERT B DIBBLE

Table of content: (NPI 1417076563)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417076563 NPI number — ROBERT B DIBBLE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROBERT B DIBBLE
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:
1417076563
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/30/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
375 E LINE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BISHOP
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93514-3566
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-873-4357
Provider Business Mailing Address Fax Number:
760-873-7446

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
375 E LINE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BISHOP
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93514-3566
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-873-4357
Provider Business Practice Location Address Fax Number:
760-873-7446
Provider Enumeration Date:
03/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DIBBLE
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
BAILEY
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
760-873-4357

Provider Taxonomy Codes

  • Taxonomy code: 261QR0405X , with the licence number:  140001AP , 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: 003336 . This is a "BLUE CROSS ID" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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