1841483427 NPI number — EAG PROFESSIONAL MEDICAL CORP.

Table of content: (NPI 1841483427)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841483427 NPI number — EAG PROFESSIONAL MEDICAL CORP.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAG PROFESSIONAL MEDICAL CORP.
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:
1841483427
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/03/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3512 HILLGLEN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MODESTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95355-7867
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-985-4813
Provider Business Mailing Address Fax Number:
209-551-3255

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1809 CENTRAL AVE STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CERES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95307-1806
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-537-4434
Provider Business Practice Location Address Fax Number:
209-551-3255
Provider Enumeration Date:
08/27/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GO
Authorized Official First Name:
ELEUTERIO
Authorized Official Middle Name:
ARCANGEL
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
209-537-4434

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  A68296 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2084P0804X , with the licence number: A68296 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 00A682962 . This is a "MEDICARE PPIN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 6213236 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZ01404Z . This is a "MEDICARE GROUP ID" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".