1700134103 NPI number — KNEE CENTERS NOCAL MEDICAL PROFESSIONAL CORPORATION

Table of content: (NPI 1700134103)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700134103 NPI number — KNEE CENTERS NOCAL MEDICAL PROFESSIONAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KNEE CENTERS NOCAL MEDICAL 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:
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:
1700134103
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/16/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
585 W 500 S
Provider Second Line Business Mailing Address:
SUITE 120
Provider Business Mailing Address City Name:
BOUNTIFUL
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84010-8199
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-617-2100
Provider Business Mailing Address Fax Number:
801-208-7050

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2675 STEVENSON BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FREMONT
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94538-2317
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-791-5633
Provider Business Practice Location Address Fax Number:
510-791-5634
Provider Enumeration Date:
08/16/2012

Additional Information

Authorized Official

Authorized Official Last Name:
HUGHES
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
650-504-8151

Provider Taxonomy Codes

  • Taxonomy code: 2081S0010X , with the licence number:  A78391 , 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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