1649204801 NPI number — TEMECULA VALLEY ORTHOITCS & PROSTHETICS, INC.

Table of content: (NPI 1649204801)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649204801 NPI number — TEMECULA VALLEY ORTHOITCS & PROSTHETICS, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TEMECULA VALLEY ORTHOITCS & PROSTHETICS, 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:
TEMECULA VALLEY O&P
Provider Other Organization Name Type Code:
4
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:
1649204801
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
36243 INLAND VALLEY DR STE 30
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILDOMAR
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92595-9547
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-696-4447
Provider Business Mailing Address Fax Number:
951-696-4448

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
36243 INLAND VALLEY DR STE 30
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILDOMAR
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92595-9547
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-696-4447
Provider Business Practice Location Address Fax Number:
951-696-4448
Provider Enumeration Date:
07/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MATHENY
Authorized Official First Name:
SHAWN
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
951-696-4447

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X , with the licence number:  CPO19140 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: ZZZ03626Z . This is a "BLUE SHIELD PROVIDER NUMB" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 4898339 . This is a "BLUE CROSS PROVIDER NUMBE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 5573 . This is a "HEALTH NET PROVIDER NUMBE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: XC0019140 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: CMS170123 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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