1972623007 NPI number — PDAP OF VENTURA COUNTY, INC.

Table of content: (NPI 1972623007)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972623007 NPI number — PDAP OF VENTURA COUNTY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PDAP OF VENTURA COUNTY, 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:
1972623007
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/18/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
07/17/2007
NPI Reactivation Date:
04/18/2016

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1029 E SANTA PAULA ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANTA PAULA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93060-2247
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-482-1265
Provider Business Mailing Address Fax Number:
805-389-5295

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
450 ROSEWOOD AVENUE
Provider Second Line Business Practice Location Address:
SUITE 215
Provider Business Practice Location Address City Name:
CAMARILLO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93010-5914
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-482-1265
Provider Business Practice Location Address Fax Number:
805-389-5295
Provider Enumeration Date:
03/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CONNELL
Authorized Official First Name:
VIRGINIA
Authorized Official Middle Name:
MARY
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
805-482-1265

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  560015EN , 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: 5673 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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