1841749041 NPI number — COAST TO COAST PODIATRY

Table of content: (NPI 1841749041)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841749041 NPI number — COAST TO COAST PODIATRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COAST TO COAST PODIATRY
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:
6
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:
1841749041
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/22/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18740 VENTURA BLVD STE 102
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TARZANA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91356-6353
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-836-2475
Provider Business Mailing Address Fax Number:
310-943-1457

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18740 VENTURA BLVD STE 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TARZANA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91356
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-836-2475
Provider Business Practice Location Address Fax Number:
310-943-1457
Provider Enumeration Date:
09/28/2016

Additional Information

Authorized Official

Authorized Official Last Name:
OTIKO
Authorized Official First Name:
CHRISTOPHER
Authorized Official Middle Name:
AYODELE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
818-836-2475

Provider Taxonomy Codes

  • Taxonomy code: 213EP1101X , with the licence number:  E4159 , 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: 1346223997 . This is a "NPI" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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