1780752659 NPI number — FULLERTON GYN ASSOC.

Table of content: (NPI 1780752659)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780752659 NPI number — FULLERTON GYN ASSOC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FULLERTON GYN ASSOC.
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:
1780752659
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/12/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
301 W BASTANCHURY RD
Provider Second Line Business Mailing Address:
#170
Provider Business Mailing Address City Name:
FULLERTON
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92835-3419
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-879-6571
Provider Business Mailing Address Fax Number:
714-446-9140

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
301 W BASTANCHURY RD
Provider Second Line Business Practice Location Address:
#170
Provider Business Practice Location Address City Name:
FULLERTON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92835-3419
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-879-6571
Provider Business Practice Location Address Fax Number:
714-446-9140
Provider Enumeration Date:
12/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SCOTT
Authorized Official First Name:
NATHAN
Authorized Official Middle Name:
E
Authorized Official Title or Position:
OWNER- CEO
Authorized Official Telephone Number:
714-879-6571

Provider Taxonomy Codes

  • Taxonomy code: 207VG0400X , with the licence number:  G5122 , 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: G5122 . This is a "MEDICAL LISENCE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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