1447476064 NPI number — THE INDUSTRIAL CLINIC AT MONTCLAIR, A MED CORP

Table of content: (NPI 1447476064)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447476064 NPI number — THE INDUSTRIAL CLINIC AT MONTCLAIR, A MED CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE INDUSTRIAL CLINIC AT MONTCLAIR, A MED CORP
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:
1447476064
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
55 S RAYMOND AVE STE 105
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALHAMBRA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91801-7100
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-289-9004
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18575 GALE AVE STE 198
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CITY OF INDUSTRY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91748-1382
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-289-9004
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WU
Authorized Official First Name:
JACK
Authorized Official Middle Name:
X
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
626-289-9004

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  A32175 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 208D00000X , with the licence number: A69486 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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





Copyright © 2007-2025 www.npivalidator.com