1972611861 NPI number — MS. BEVERLY A BORELLA PTA

Table of content: MS. BEVERLY A BORELLA PTA (NPI 1972611861)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972611861 NPI number — MS. BEVERLY A BORELLA PTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BORELLA
Provider First Name:
BEVERLY
Provider Middle Name:
A
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PTA
Provider Gender Code:
F

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:
1972611861
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
53585 DOGWOOD DR
Provider Second Line Business Mailing Address:
PO BOX 1521
Provider Business Mailing Address City Name:
NORTH FORK
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93643-9720
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
559-877-4191
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5533 W HILLSDALE AVE
Provider Second Line Business Practice Location Address:
SUITE 'A'
Provider Business Practice Location Address City Name:
VISALIA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93291-5138
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-733-2478
Provider Business Practice Location Address Fax Number:
559-733-2470
Provider Enumeration Date:
08/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225200000X , with the licence number:  AT1615 , 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: AT1615 . This is a "PTA LICENSE NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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