1417687971 NPI number — ASHLEY ELIZABETH PALOMO DIAZ M.ED.

Table of content: ASHLEY ELIZABETH PALOMO DIAZ M.ED. (NPI 1417687971)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417687971 NPI number — ASHLEY ELIZABETH PALOMO DIAZ M.ED.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PALOMO DIAZ
Provider First Name:
ASHLEY
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.ED.
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:
1417687971
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/16/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
985 E 2ND ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN BERNARDINO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92408-1273
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-343-9221
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21801 CACTUS AVE STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARCH ARB
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92518-3020
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
833-526-2333
Provider Business Practice Location Address Fax Number:
855-621-9293
Provider Enumeration Date:
06/16/2022

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: 106S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1679041495 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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