1831352715 NPI number — DMJ MEDICAL SERVICES, INC

Table of content: (NPI 1831352715)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831352715 NPI number — DMJ MEDICAL SERVICES, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DMJ MEDICAL SERVICES, INC
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:
1831352715
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/17/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
702 MANGROVE AVE
Provider Second Line Business Mailing Address:
PMB 313
Provider Business Mailing Address City Name:
CHICO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95926-3948
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
530-566-0132
Provider Business Mailing Address Fax Number:
530-566-1682

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1025 VILLAGE LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95926-2812
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-566-0132
Provider Business Practice Location Address Fax Number:
530-566-1682
Provider Enumeration Date:
07/09/2008

Additional Information

Authorized Official

Authorized Official Last Name:
GARRISON
Authorized Official First Name:
MARK
Authorized Official Middle Name:
S.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
530-566-0132

Provider Taxonomy Codes

  • Taxonomy code: 207VG0400X , with the licence number:  20A9268 , 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: DP0994 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1831352715 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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