1639212574 NPI number — JACQUELINE G. AGCAOILI, MD CORPORATION

Table of content: (NPI 1639212574)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639212574 NPI number — JACQUELINE G. AGCAOILI, MD CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JACQUELINE G. AGCAOILI, MD CORPORATION
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:
1639212574
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/29/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4440 BROCKTON AVE
Provider Second Line Business Mailing Address:
SUITE 320
Provider Business Mailing Address City Name:
RIVERSIDE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92501-4068
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-369-6191
Provider Business Mailing Address Fax Number:
951-369-0304

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4440 BROCKTON AVE
Provider Second Line Business Practice Location Address:
SUITE 320
Provider Business Practice Location Address City Name:
RIVERSIDE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92501-4068
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-369-6191
Provider Business Practice Location Address Fax Number:
951-369-0304
Provider Enumeration Date:
02/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
AGCAOILI
Authorized Official First Name:
JACQUELINE
Authorized Official Middle Name:
GESNER
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
951-369-6191

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  A46231 , 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: 00A462310 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com