1932287620 NPI number — MICHAEL J ILAS DO A CALIFORNIA PROFESSIONAL MEDICAL CORP

Table of content: DR. MICHELLE RAE NIESET D.D.S (NPI 1720235914)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932287620 NPI number — MICHAEL J ILAS DO A CALIFORNIA PROFESSIONAL MEDICAL CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHAEL J ILAS DO A CALIFORNIA PROFESSIONAL MEDICAL CORP
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:
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:
1932287620
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:
PO BOX 892577
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TEMECULA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92589-2577
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
562-866-1895
Provider Business Mailing Address Fax Number:
562-866-5730

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
34859 FREDRICK STREET
Provider Second Line Business Practice Location Address:
SUITE 111
Provider Business Practice Location Address City Name:
WILDOMAR
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92595
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-866-1895
Provider Business Practice Location Address Fax Number:
562-866-5730
Provider Enumeration Date:
11/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ILAS
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PROVIDER
Authorized Official Telephone Number:
562-866-1895

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  20A6560 , 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: 20A6560 . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 00AX65601 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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