1861787079 NPI number — TINA ROBINSON GELLER MPT

Table of content: TINA ROBINSON GELLER MPT (NPI 1861787079)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861787079 NPI number — TINA ROBINSON GELLER MPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GELLER
Provider First Name:
TINA
Provider Middle Name:
ROBINSON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ROBINSON
Provider Other First Name:
TINA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1861787079
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/02/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24630 WASHINGTON AVE
Provider Second Line Business Mailing Address:
200
Provider Business Mailing Address City Name:
MURRIETA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92562-6177
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-696-9353
Provider Business Mailing Address Fax Number:
951-973-7216

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15200 W SUNSET BLVD
Provider Second Line Business Practice Location Address:
111
Provider Business Practice Location Address City Name:
PACIFIC PALISADES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90272-3619
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-573-9340
Provider Business Practice Location Address Fax Number:
310-573-9328
Provider Enumeration Date:
06/15/2011

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: 225100000X , with the licence number:  PT 36921 , 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: 0PT369210 . This is a "BLUE SHIELD OF CALIFORNIA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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