1639319254 NPI number — CLINICA MEDICA DR RENE DELGADO, 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 1639319254 NPI number — CLINICA MEDICA DR RENE DELGADO, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLINICA MEDICA DR RENE DELGADO, 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:
1639319254
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/22/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
189 MEDICAL WAY
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
RIVERDALE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30274-4905
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-996-9681
Provider Business Mailing Address Fax Number:
770-996-9683

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
189 MEDICAL WAY
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
RIVERDALE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30274-4905
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-996-9681
Provider Business Practice Location Address Fax Number:
770-996-9683
Provider Enumeration Date:
02/22/2009

Additional Information

Authorized Official

Authorized Official Last Name:
DOURRON
Authorized Official First Name:
JACK
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
770-996-9681

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  027722 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 014308 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000348675A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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