1871575928 NPI number — MAXQUINDOM INC

Table of content: CRAIG JAMES JENSON LMT (NPI 1831944263)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871575928 NPI number — MAXQUINDOM INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAXQUINDOM INC
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:
1871575928
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
730 S CENTRAL AVE
Provider Second Line Business Mailing Address:
SUITE 212
Provider Business Mailing Address City Name:
GLENDALE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91204-2061
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-550-8268
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
730 S CENTRAL AVE
Provider Second Line Business Practice Location Address:
SUITE 212
Provider Business Practice Location Address City Name:
GLENDALE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91204-2061
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-550-8268
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/15/2005

Additional Information

Authorized Official

Authorized Official Last Name:
SY
Authorized Official First Name:
ALLAN
Authorized Official Middle Name:
A
Authorized Official Title or Position:
DIRECTOR OF PATIENT CARE SERVICES
Authorized Official Telephone Number:
818-550-8268

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , 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: HHA57600G , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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