1669923546 NPI number — ROSAMOND MEDICAL CLINIC

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 1669923546 NPI number — ROSAMOND MEDICAL CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROSAMOND MEDICAL CLINIC
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:
1669923546
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/17/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
41019 WOODSHIRE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALMDALE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93551-5746
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
559-772-8503
Provider Business Mailing Address Fax Number:
559-772-8504

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1415 W ROSAMOND BLVD
Provider Second Line Business Practice Location Address:
#24
Provider Business Practice Location Address City Name:
ROSAMOND
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93560-7429
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-772-8503
Provider Business Practice Location Address Fax Number:
559-772-8504
Provider Enumeration Date:
10/17/2016

Additional Information

Authorized Official

Authorized Official Last Name:
ALI
Authorized Official First Name:
ASHMEAD
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
559-772-8503

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  G078625 , 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)

  • Identifier: G078625 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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