1548852171 NPI number — MATHIEU JOSEPH AGBAYANI MOULIC

Table of content: MATHIEU JOSEPH AGBAYANI MOULIC (NPI 1548852171)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548852171 NPI number — MATHIEU JOSEPH AGBAYANI MOULIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOULIC
Provider First Name:
MATHIEU JOSEPH
Provider Middle Name:
AGBAYANI
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

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:
1548852171
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/04/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
322 EOLA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WALNUT
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91789-2249
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-859-4410
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
433 N 4TH ST STE 216
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONTEBELLO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90640-4309
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-530-0433
Provider Business Practice Location Address Fax Number:
323-530-0434
Provider Enumeration Date:
02/04/2021

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:  299815 , 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)





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