1962597807 NPI number — ADVANCED CALIFORNIA MEDICAL CENTER, INC.

Table of content: (NPI 1962597807)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962597807 NPI number — ADVANCED CALIFORNIA MEDICAL CENTER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED CALIFORNIA MEDICAL CENTER, 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:
1962597807
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/20/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1934 VIA CASA ALTA
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LA JOLLA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92037-5730
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-578-9600
Provider Business Mailing Address Fax Number:
858-578-9065

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10737 CAMINO RUIZ
Provider Second Line Business Practice Location Address:
SUITE 114
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92126-2359
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-578-9600
Provider Business Practice Location Address Fax Number:
858-578-9065
Provider Enumeration Date:
10/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TAJRAN
Authorized Official First Name:
DEENA
Authorized Official Middle Name:
S
Authorized Official Title or Position:
OWNER PRESIDENT
Authorized Official Telephone Number:
858-578-9600

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  A55154 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: A55154 , 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: ZZZ65932Z . This is a "BLUE SHIELD CA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ65933Z . This is a "BLUE SHIELD CA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 774581 . This is a "BLUE SHIELD CA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 00A551540 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZ65931Z . This is a "BLUE SHIELD CA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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