1639448228 NPI number — JACLYN LORI TROTTER NGUYEN DPT

Table of content: JACLYN LORI TROTTER NGUYEN DPT (NPI 1639448228)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639448228 NPI number — JACLYN LORI TROTTER NGUYEN DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NGUYEN
Provider First Name:
JACLYN
Provider Middle Name:
LORI TROTTER
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TROTTER
Provider Other First Name:
JACLYN
Provider Other Middle Name:
LORI
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1639448228
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/14/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24630 WASHINGTON AVE
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
MURRIETA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92562-6177
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-696-9353
Provider Business Mailing Address Fax Number:
951-973-7216

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
886 MAGNOLIA AVE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
CORONA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92879-3105
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-340-3402
Provider Business Practice Location Address Fax Number:
951-340-3416
Provider Enumeration Date:
12/28/2011

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: 225100000X , with the licence number:  PT 38662 , 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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