1588787790 NPI number — SERRA COMMUNITY MEDICAL CLINIC, INC

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 1588787790 NPI number — SERRA COMMUNITY MEDICAL CLINIC, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SERRA COMMUNITY MEDICAL CLINIC, 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:
6
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:
1588787790
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9375 SAN FERNANDO RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUN VALLEY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91352-1418
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-768-3000
Provider Business Mailing Address Fax Number:
818-504-4690

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9375 SAN FERNANDO RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUN VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91352-1418
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-768-3000
Provider Business Practice Location Address Fax Number:
818-504-4690
Provider Enumeration Date:
04/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DURAIRAJ
Authorized Official First Name:
SADAYAPPA
Authorized Official Middle Name:
K
Authorized Official Title or Position:
C.E.O.
Authorized Official Telephone Number:
818-768-3000

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  930000976 , 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: SUR01546F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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