1730254145 NPI number — SUNRISE SHOES & PEDORTHIC SERVICE

Table of content: MRS. RONNI GORDON BERGMAN NP (NPI 1942253117)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730254145 NPI number — SUNRISE SHOES & PEDORTHIC SERVICE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUNRISE SHOES & PEDORTHIC SERVICE
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:
1730254145
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/21/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3127 FITE CIR
Provider Second Line Business Mailing Address:
SUITE G
Provider Business Mailing Address City Name:
SACRAMENTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95827-1803
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-368-7700
Provider Business Mailing Address Fax Number:
916-368-7717

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3127 FITE CIR
Provider Second Line Business Practice Location Address:
SUITE G
Provider Business Practice Location Address City Name:
SACRAMENTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95827-1803
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-368-7700
Provider Business Practice Location Address Fax Number:
916-368-7717
Provider Enumeration Date:
11/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DURANTE
Authorized Official First Name:
MICHELLE
Authorized Official Middle Name:
NICHOLLE
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
916-368-7700

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , 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: GXC000820 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0127817 . This is a "KAISER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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