1720486483 NPI number — CARISSA STUCK

Table of content: CARISSA STUCK (NPI 1720486483)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720486483 NPI number — CARISSA STUCK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STUCK
Provider First Name:
CARISSA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

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:
1720486483
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/11/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
505 N BRAND BLVD
Provider Second Line Business Mailing Address:
#1000
Provider Business Mailing Address City Name:
GLENDALE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91203-1906
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-241-6780
Provider Business Mailing Address Fax Number:
818-241-6853

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3111 N TUSTIN ST
Provider Second Line Business Practice Location Address:
#100
Provider Business Practice Location Address City Name:
ORANGE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92865-1750
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
855-295-3276
Provider Business Practice Location Address Fax Number:
818-241-6853
Provider Enumeration Date:
12/11/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  RPE 9554 , 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: RPE 9554 . This is a "SLP" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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