1669500724 NPI number — MS. ELLEN PESKIN LICENSED MARRIAGE FA

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 1669500724 NPI number — MS. ELLEN PESKIN LICENSED MARRIAGE FA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PESKIN
Provider First Name:
ELLEN
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LICENSED MARRIAGE FA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GEISINGER
Provider Other First Name:
ELLEN
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1669500724
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3901 ENOS AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAKLAND
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94619
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-479-7151
Provider Business Mailing Address Fax Number:
510-479-7151

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
23 MASONIC AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN FRANCISCO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94118
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
415-922-4525
Provider Business Practice Location Address Fax Number:
510-479-7151
Provider Enumeration Date:
03/01/2007

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: 106H00000X , with the licence number:  MFT12207 , 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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