1518148857 NPI number — NEW HAVEN ICF-DDH

Table of content: (NPI 1518148857)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518148857 NPI number — NEW HAVEN ICF-DDH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEW HAVEN ICF-DDH
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:
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:
1518148857
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/15/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 SAWYER ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VALLEJO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94589-2039
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-648-2340
Provider Business Mailing Address Fax Number:
707-648-1549

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 SAWYER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VALLEJO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94589-2039
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-648-2340
Provider Business Practice Location Address Fax Number:
707-648-1549
Provider Enumeration Date:
11/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PADILLA
Authorized Official First Name:
LEONILA
Authorized Official Middle Name:
REALEZA
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
707-655-3225

Provider Taxonomy Codes

  • Taxonomy code: 320600000X , with the licence number:  010000133 , 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: LTC60123H . This is a "MEDICAL PROVIDER NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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