1750491247 NPI number — PRIME HEALTHCARE SERVICES - SHERMAN OAKS, LLC

Table of content: (NPI 1750491247)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750491247 NPI number — PRIME HEALTHCARE SERVICES - SHERMAN OAKS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRIME HEALTHCARE SERVICES - SHERMAN OAKS, 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:
6
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:
1750491247
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/14/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3300 E GUASTI RD
Provider Second Line Business Mailing Address:
3RD FLOOR
Provider Business Mailing Address City Name:
ONTARIO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91761-8655
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-235-4400
Provider Business Mailing Address Fax Number:
909-235-4419

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4929 VAN NUYS BLVD.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHERMAN OAKS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91403-1702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-981-7111
Provider Business Practice Location Address Fax Number:
818-501-6430
Provider Enumeration Date:
08/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
REDDY
Authorized Official First Name:
PREM
Authorized Official Middle Name:
Authorized Official Title or Position:
CHAIRMAN/PRES/CEO
Authorized Official Telephone Number:
909-235-4400

Provider Taxonomy Codes

  • Taxonomy code: 282N00000X , with the licence number:  930000149 , 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: HSP301141 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: HSP30114I , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: HSP401141 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZA1966Z . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: HSC30114I , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: HSC301141 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: HSP40114I , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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