1902192362 NPI number — SAN MANUEL MEDICAL CLINIC, INC

Table of content: (NPI 1902192362)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902192362 NPI number — SAN MANUEL MEDICAL CLINIC, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAN MANUEL MEDICAL CLINIC, 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:
1902192362
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/11/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7400 PACIFIC BLVD
Provider Second Line Business Mailing Address:
SUITE# A-B
Provider Business Mailing Address City Name:
WALNUT PARK
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90255-5739
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
323-584-8881
Provider Business Mailing Address Fax Number:
323-584-8882

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7400 PACIFIC BLVD
Provider Second Line Business Practice Location Address:
A
Provider Business Practice Location Address City Name:
HUNTINGTON PARK
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90255-5739
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-584-8881
Provider Business Practice Location Address Fax Number:
323-584-8882
Provider Enumeration Date:
06/23/2011

Additional Information

Authorized Official

Authorized Official Last Name:
RUIZ
Authorized Official First Name:
PHILLIP
Authorized Official Middle Name:
A
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
323-584-8881

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  A30390 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: A41503 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: PA15560 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: A44599 , 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: PA15560 . This is a "MULTI-SPECIALTY GROUP-PHYSICIAN ASSISTANT" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: A44599 . This is a "MULTI-SPECIALTY GROUP- FAMILY MEDICINE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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