1720265093 NPI number — AQUILA HEALTHCARE SYSTEMS, LLC

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 1720265093 NPI number — AQUILA HEALTHCARE SYSTEMS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AQUILA HEALTHCARE SYSTEMS, LLC
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:
1720265093
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/02/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
400 CORPORATE POINTE STE 300-56
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CULVER CITY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90230-7615
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
213-380-1399
Provider Business Mailing Address Fax Number:
213-380-4046

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3450 WILSHIRE BLVD
Provider Second Line Business Practice Location Address:
SUITE 1000
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90010-2208
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-380-1399
Provider Business Practice Location Address Fax Number:
213-380-4046
Provider Enumeration Date:
01/29/2008

Additional Information

Authorized Official

Authorized Official Last Name:
CLARK
Authorized Official First Name:
DAMON
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
213-380-1399

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  980000772 , 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: 200320310073 . This is a "CA LLC FILE NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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