1861872244 NPI number — BIANCA TALAVERA

Table of content: BIANCA TALAVERA (NPI 1861872244)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861872244 NPI number — BIANCA TALAVERA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TALAVERA
Provider First Name:
BIANCA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

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:
1861872244
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/08/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9808 VENICE BLVD., STE. 505
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CULVER CITY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90232-2803
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
562-216-4900
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4335 ATLANTIC AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONG BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90807-2803
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-216-4900
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/01/2015

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: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 941735271 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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