1578756979 NPI number — LEISURE YU, MD, INC.

Table of content: (NPI 1578756979)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578756979 NPI number — LEISURE YU, MD, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LEISURE YU, MD, 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:
1578756979
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/11/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
30688 COUNTRY CLUB DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
REDLANDS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92373-7619
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-214-2105
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10459 MT VIEW AVE
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
LOMA LINDA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92354-2033
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-799-3838
Provider Business Practice Location Address Fax Number:
909-799-3830
Provider Enumeration Date:
08/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
YU
Authorized Official First Name:
LEISURE
Authorized Official Middle Name:
Authorized Official Title or Position:
AUTHORIZED OFFICAL
Authorized Official Telephone Number:
909-214-2105

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  G62381 , 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: 602135600 . This is a "US DEPT OF LABOR" identifier . This identifiers is of the category "OTHER".
  • Identifier: 00G623810 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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