1568686814 NPI number — DR. TIMOTHY PHEASANT ANGELO D.C.

Table of content: DR. TIMOTHY PHEASANT ANGELO D.C. (NPI 1568686814)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568686814 NPI number — DR. TIMOTHY PHEASANT ANGELO D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANGELO
Provider First Name:
TIMOTHY
Provider Middle Name:
PHEASANT
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.C.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ANGELO
Provider Other First Name:
JOHN-TIMOTHY
Provider Other Middle Name:
PHEASANT
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
D.C.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1568686814
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/24/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
903 EMBARCADERO DR
Provider Second Line Business Mailing Address:
STE 4
Provider Business Mailing Address City Name:
EL DORADO HILLS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95762-4098
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-933-9870
Provider Business Mailing Address Fax Number:
916-933-3540

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
903 EMBARCADERO DR
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
EL DORADO HILLS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95762-4098
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-933-9870
Provider Business Practice Location Address Fax Number:
916-933-2708
Provider Enumeration Date:
04/11/2007

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: 111NS0005X , with the licence number:  30036 , 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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