1568636009 NPI number — J O MEDICAL PROFESSIONAL CORPORATION

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 1568636009 NPI number — J O MEDICAL PROFESSIONAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
J O MEDICAL PROFESSIONAL CORPORATION
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:
1568636009
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1325 EAST WINDSOR RD
Provider Second Line Business Mailing Address:
4
Provider Business Mailing Address City Name:
GLENDALE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91205-6277
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-292-8000
Provider Business Mailing Address Fax Number:
818-507-6414

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13739 RIVESIDE DRIVE
Provider Second Line Business Practice Location Address:
UNIT B
Provider Business Practice Location Address City Name:
SHERMAN OAKS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91423-2417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-292-8000
Provider Business Practice Location Address Fax Number:
818-507-6414
Provider Enumeration Date:
04/16/2008

Additional Information

Authorized Official

Authorized Official Last Name:
OGANESSIAN
Authorized Official First Name:
JANNA
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
818-292-8000

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  A79854 , 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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