1609975317 NPI number — MR. JUSTIN M BROADBENT NP

Table of content: MR. JUSTIN M BROADBENT NP (NPI 1609975317)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609975317 NPI number — MR. JUSTIN M BROADBENT NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROADBENT
Provider First Name:
JUSTIN
Provider Middle Name:
M
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
M

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:
1609975317
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
489 HIGGINS ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FOLSOM
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95630-9564
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-985-9670
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2288 AUBURN BLVD
Provider Second Line Business Practice Location Address:
SUITE 106
Provider Business Practice Location Address City Name:
SACRAMENTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95821-1618
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-568-8338
Provider Business Practice Location Address Fax Number:
916-925-3985
Provider Enumeration Date:
09/21/2006

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: 363L00000X , with the licence number:  NP15480 , 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: RN404646 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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