1528023306 NPI number — AMIGO MEDICAL GROUP, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528023306 NPI number — AMIGO MEDICAL GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AMIGO MEDICAL GROUP, INC.
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:
1528023306
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:
386 E H ST
Provider Second Line Business Mailing Address:
SUITE 210
Provider Business Mailing Address City Name:
CHULA VISTA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91910-7485
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-427-5053
Provider Business Mailing Address Fax Number:
619-427-1437

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
386 E H ST
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
CHULA VISTA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91910-7485
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-427-5053
Provider Business Practice Location Address Fax Number:
619-427-1437
Provider Enumeration Date:
04/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MONAHAN
Authorized Official First Name:
SALLY
Authorized Official Middle Name:
ANDERSON
Authorized Official Title or Position:
SECRETARY TREASURER
Authorized Official Telephone Number:
619-427-5053

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  FNP 4774 , 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: GR0046550 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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