1639540560 NPI number — PROFESSIONAL ADVANTAGE MEDICAL GROUP

Table of content: (NPI 1639540560)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639540560 NPI number — PROFESSIONAL ADVANTAGE MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROFESSIONAL ADVANTAGE MEDICAL GROUP
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:
1639540560
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/30/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
38713 TIERRA SUBIDA AVE
Provider Second Line Business Mailing Address:
SUITE 200-315
Provider Business Mailing Address City Name:
PALMDALE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93551-4562
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-233-2228
Provider Business Mailing Address Fax Number:
714-985-9053

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1041 E YORBA LINDA BLVD
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
PLACENTIA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92870-3728
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-985-9110
Provider Business Practice Location Address Fax Number:
714-985-9053
Provider Enumeration Date:
10/19/2015

Additional Information

Authorized Official

Authorized Official Last Name:
GAMBOL
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
Authorized Official Title or Position:
C.E.O
Authorized Official Telephone Number:
850-233-2228

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208D00000X , with the licence number: G87090 , 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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