1639355381 NPI number — JOHN W. SCIVALLY, D.P.M INC

Table of content: (NPI 1639355381)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639355381 NPI number — JOHN W. SCIVALLY, D.P.M INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOHN W. SCIVALLY, D.P.M 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:
1639355381
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/26/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2227 OLYMPIC BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WALNUT CREEK
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94595-1623
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
925-937-2860
Provider Business Mailing Address Fax Number:
925-937-5565

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2227 OLYMPIC BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WALNUT CREEK
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94595-1623
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
925-937-2860
Provider Business Practice Location Address Fax Number:
925-937-5565
Provider Enumeration Date:
01/11/2008

Additional Information

Authorized Official

Authorized Official Last Name:
SCIVALLY
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
W
Authorized Official Title or Position:
OWNER/ PHYSICIAN
Authorized Official Telephone Number:
925-937-2860

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  E4319 , 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: 000E43190 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com