1548256829 NPI number — MR. CARLOS YANCEY ROMERO MPT

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 1548256829 NPI number — MR. CARLOS YANCEY ROMERO MPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROMERO
Provider First Name:
CARLOS
Provider Middle Name:
YANCEY
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MPT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ROMERO MPT
Provider Other First Name:
CARLOS
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1548256829
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12139 MOUNT VERNON AVE
Provider Second Line Business Mailing Address:
SUITE 110
Provider Business Mailing Address City Name:
GRAND TERRACE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92313-5586
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-370-3396
Provider Business Mailing Address Fax Number:
909-783-4288

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10537 MAGNOLIA BLVD
Provider Second Line Business Practice Location Address:
REHAB DEPT
Provider Business Practice Location Address City Name:
N HOLLYWOOD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91601-4114
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-508-9293
Provider Business Practice Location Address Fax Number:
818-508-9293
Provider Enumeration Date:
09/22/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT29686 , 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: OPT296880 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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