1467506451 NPI number — HALO MEDICAL GROUP

Table of content: (NPI 1467506451)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467506451 NPI number — HALO MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HALO MEDICAL GROUP
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:
1467506451
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/22/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 841163
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90084-1163
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-776-8989
Provider Business Mailing Address Fax Number:
760-779-8073

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
74785 US HIGHWAY 111
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
INDIAN WELLS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92210-7128
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-776-8989
Provider Business Practice Location Address Fax Number:
760-501-0311
Provider Enumeration Date:
01/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HAMMOND
Authorized Official First Name:
CORY
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
760-776-8989

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085N0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0204X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085U0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: FNP25453 , 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: ZZZ02402Z . This is a "BLUE SHIELD PIN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ02402Z . This is a "BLUE CROSS" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ64094Z . This is a "BLUE SHIELD PIN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ64094Z . This is a "BLUE CROSS" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0083072 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0083073 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: CK9031 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ57290Z . This is a "BLUE SHIELD PIN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ05859Z . This is a "BLUE CROSS" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ57290Z . This is a "BLUE CROSS" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0083070 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0083071 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZ05859Z . This is a "BLUE SHIELD PIN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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