1457547291 NPI number — ERIC J. LAUDENSLAGER

Table of content: (NPI 1457547291)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457547291 NPI number — ERIC J. LAUDENSLAGER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ERIC J. LAUDENSLAGER
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:
1457547291
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/18/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
33492 OAK GLEN RD
Provider Second Line Business Mailing Address:
H
Provider Business Mailing Address City Name:
YUCAIPA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92399-2096
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-797-5155
Provider Business Mailing Address Fax Number:
909-797-2768

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1630 W REDLANDS BLVD
Provider Second Line Business Practice Location Address:
L
Provider Business Practice Location Address City Name:
REDLANDS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92373-8032
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-797-5155
Provider Business Practice Location Address Fax Number:
909-797-2768
Provider Enumeration Date:
09/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LAUDENSLAGER
Authorized Official First Name:
ERIC
Authorized Official Middle Name:
Authorized Official Title or Position:
PT/OWNER
Authorized Official Telephone Number:
909-797-5155

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , with the licence number:  PT8450 , 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: 00PT84502 . This is a "MEDICARE PTAN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com