1720439755 NPI number — SECRETS OF THE ISLAND

Table of content: (NPI 1720439755)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720439755 NPI number — SECRETS OF THE ISLAND

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SECRETS OF THE ISLAND
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:
1720439755
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/20/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3821 ATLANTIC AVE
Provider Second Line Business Mailing Address:
SUITE F
Provider Business Mailing Address City Name:
LONG BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90807-3534
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
562-940-5450
Provider Business Mailing Address Fax Number:
562-424-3235

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3821 ATLANTIC AVE
Provider Second Line Business Practice Location Address:
SUITE F
Provider Business Practice Location Address City Name:
LONG BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90807-3534
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-940-5450
Provider Business Practice Location Address Fax Number:
562-424-3235
Provider Enumeration Date:
06/30/2016

Additional Information

Authorized Official

Authorized Official Last Name:
PEREZ
Authorized Official First Name:
ELIZABETH
Authorized Official Middle Name:
A
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
562-940-5450

Provider Taxonomy Codes

  • Taxonomy code: 171W00000X , with the licence number:  171W00000X , 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: 1720439755 . This is a "NPI" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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