1609135029 NPI number — M&G CUSTOM SHOES AND ORTHOTICS LLC

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 1609135029 NPI number — M&G CUSTOM SHOES AND ORTHOTICS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
M&G CUSTOM SHOES AND ORTHOTICS LLC
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:
1609135029
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/09/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1504 A ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANTIOCH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94509-2333
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
925-305-1855
Provider Business Mailing Address Fax Number:
925-755-8601

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2950 BUSKIRK AVE
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
WALNUT CREEK
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94597-7779
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
925-305-1855
Provider Business Practice Location Address Fax Number:
925-755-8601
Provider Enumeration Date:
05/04/2012

Additional Information

Authorized Official

Authorized Official Last Name:
BANTING
Authorized Official First Name:
GREGORY
Authorized Official Middle Name:
R
Authorized Official Title or Position:
OWNER/PARTNER
Authorized Official Telephone Number:
925-305-1855

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X , with the licence number:  CPED0350 , 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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