1720217698 NPI number — MIRACLE WOMEN'S 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 1720217698 NPI number — MIRACLE WOMEN'S MEDICAL GROUP INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIRACLE WOMEN'S 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:
1720217698
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/20/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 260185
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ENCINO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91426-0185
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-212-8339
Provider Business Mailing Address Fax Number:
949-502-8887

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7100 VAN NUYS BLVD
Provider Second Line Business Practice Location Address:
SUITE 113
Provider Business Practice Location Address City Name:
VAN NUYS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91405-3063
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-909-0004
Provider Business Practice Location Address Fax Number:
818-909-0008
Provider Enumeration Date:
07/13/2009

Additional Information

Authorized Official

Authorized Official Last Name:
MOVASSAGHI
Authorized Official First Name:
VON
Authorized Official Middle Name:
Authorized Official Title or Position:
BILLING MANAGER
Authorized Official Telephone Number:
949-212-8339

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  A96648 , 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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