1912062647 NPI number — PETRECCIA AND TROTTER MEDICAL CORPORATION

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912062647 NPI number — PETRECCIA AND TROTTER MEDICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PETRECCIA AND TROTTER MEDICAL CORPORATION
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:
1912062647
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/04/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1275 N. ROSE DRIVE
Provider Second Line Business Mailing Address:
SUITE 134
Provider Business Mailing Address City Name:
PLACENTIA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92870-3919
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-996-6500
Provider Business Mailing Address Fax Number:
714-996-1722

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1275 N. ROSE DRIVE
Provider Second Line Business Practice Location Address:
SUITE 134
Provider Business Practice Location Address City Name:
PLACENTIA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92870-3919
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-996-6500
Provider Business Practice Location Address Fax Number:
714-996-1722
Provider Enumeration Date:
12/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TROTTER
Authorized Official First Name:
JOEL
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
714-996-6500

Provider Taxonomy Codes

  • Taxonomy code: 207RI0200X , with the licence number:  G65207 , 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: W15729 . This is a "PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: GR0048130 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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