1679714166 NPI number — ACCESS WOUND CARE AND PODIATRY CARE CLINIC

Table of content: (NPI 1679714166)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679714166 NPI number — ACCESS WOUND CARE AND PODIATRY CARE CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ACCESS WOUND CARE AND PODIATRY CARE 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:
1679714166
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/13/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1510 S. CENTRAL AVE
Provider Second Line Business Mailing Address:
SUITE 120
Provider Business Mailing Address City Name:
GLENDALE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91204
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-480-3338
Provider Business Mailing Address Fax Number:
818-790-3121

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1510 S CENTRAL AVE
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
GLENDALE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91204-2500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-480-3338
Provider Business Practice Location Address Fax Number:
818-790-3121
Provider Enumeration Date:
03/13/2009

Additional Information

Authorized Official

Authorized Official Last Name:
BLAINE
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
Authorized Official Title or Position:
DPM
Authorized Official Telephone Number:
800-480-3338

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  E3817 , 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: 000E38170 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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