1669575718 NPI number — PHILIP EBERSOLE M D FAMILY PRACTICE PROFESSIONAL CORPORATION

Table of content: (NPI 1669575718)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669575718 NPI number — PHILIP EBERSOLE M D FAMILY PRACTICE PROFESSIONAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHILIP EBERSOLE M D FAMILY PRACTICE PROFESSIONAL CORPORATION
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:
1669575718
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/25/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
30650 RANCHO CALIFORNIA RD STE D406-145
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TEMECULA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92591-3215
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-894-6868
Provider Business Mailing Address Fax Number:
951-894-6860

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25405 HANCOCK AVE
Provider Second Line Business Practice Location Address:
SUITE 204
Provider Business Practice Location Address City Name:
MURRIETA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92562-5982
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-894-6868
Provider Business Practice Location Address Fax Number:
951-894-6860
Provider Enumeration Date:
09/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
EBERSOLE
Authorized Official First Name:
EVA
Authorized Official Middle Name:
MARIA
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
951-894-6868

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  C431720 , 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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