1770208720 NPI number — VMPA LLC

Table of content: (NPI 1770208720)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770208720 NPI number — VMPA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VMPA 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:
1770208720
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/11/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4016 GRAND AVE STE A-1058
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHINO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91710-5491
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-523-8956
Provider Business Mailing Address Fax Number:
626-657-2778

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
867 E 11TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
UPLAND
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91786-4867
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-985-1981
Provider Business Practice Location Address Fax Number:
909-308-1103
Provider Enumeration Date:
10/11/2022

Additional Information

Authorized Official

Authorized Official Last Name:
DITULLIO
Authorized Official First Name:
CAROLINE
Authorized Official Middle Name:
TAPANG
Authorized Official Title or Position:
CO-MANAGER
Authorized Official Telephone Number:
626-523-8956

Provider Taxonomy Codes

  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: ZZT06136I , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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