1710349055 NPI number — CRISMALI PODIATRIC MEDICAL CORP

Table of content: (NPI 1710349055)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710349055 NPI number — CRISMALI PODIATRIC MEDICAL CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CRISMALI PODIATRIC MEDICAL CORP
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:
1710349055
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/03/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18151 BEAR VALLEY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HESPERIA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92345-4907
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-948-7400
Provider Business Mailing Address Fax Number:
760-948-7866

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 SOUTH 7TH AVENUE, SUITE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BARSTOW
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92311-3056
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-948-7400
Provider Business Practice Location Address Fax Number:
760-948-7866
Provider Enumeration Date:
03/25/2016

Additional Information

Authorized Official

Authorized Official Last Name:
CRISMALI
Authorized Official First Name:
NICHOLAS
Authorized Official Middle Name:
C.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
760-948-7400

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  E3433 , 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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