1952526675 NPI number — SOUTH CERRITOS MEDICAL GROUP, INC.

Table of content: (NPI 1952526675)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952526675 NPI number — SOUTH CERRITOS MEDICAL GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH CERRITOS MEDICAL GROUP, 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:
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:
1952526675
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:
13381 SILVER BERRY CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CERRITOS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90703-1374
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
562-809-1434
Provider Business Mailing Address Fax Number:
562-809-1526

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20927 NORWALK BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKEWOOD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90715-1545
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-809-1434
Provider Business Practice Location Address Fax Number:
562-809-1526
Provider Enumeration Date:
04/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GOINGS
Authorized Official First Name:
CONCHITA
Authorized Official Middle Name:
YATAR
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
562-809-1434

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  A41071 , 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: A41071 . This is a "STATE LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: W13073 . This is a "GROUP NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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