1841670130 NPI number — CLIFF OWL III

Table of content: CLIFF OWL III (NPI 1841670130)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841670130 NPI number — CLIFF OWL III

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OWL
Provider First Name:
CLIFF
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
III
Provider Credential Text:
Provider Gender Code:
M

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:
1841670130
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/22/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2001 28TH STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAKLAND
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94608
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
828-557-2264
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4175 LAKESIDE DRIVE
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
RICHMOND
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94806
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-262-6551
Provider Business Practice Location Address Fax Number:
510-222-7085
Provider Enumeration Date:
06/02/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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