1669686796 NPI number — PROHEALTH PARTNERS, A MEDICAL GROUP, INC.

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 1669686796 NPI number — PROHEALTH PARTNERS, A MEDICAL GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROHEALTH PARTNERS, A MEDICAL GROUP, 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:
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:
1669686796
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/16/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1045 ATLANTIC AVENUE
Provider Second Line Business Mailing Address:
SUITE 705
Provider Business Mailing Address City Name:
LONG BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90813
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1045 ATLANTIC AVENUE
Provider Second Line Business Practice Location Address:
SUITE 611
Provider Business Practice Location Address City Name:
LONG BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90813
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-437-2801
Provider Business Practice Location Address Fax Number:
562-432-0111
Provider Enumeration Date:
05/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LUGLIANI
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
562-491-9281

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: GR0015761 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZ69885Z . This is a "BLUE SHIELD OF CALIFORNIA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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