1972636009 NPI number — PAVILION NEUROLOGY MEDICAL GROUP INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972636009 NPI number — PAVILION NEUROLOGY MEDICAL GROUP INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAVILION NEUROLOGY 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:
1972636009
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1140 W LA VETA AVE STE 730
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORANGE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92868-4229
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-541-6800
Provider Business Mailing Address Fax Number:
714-541-1591

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1140 W LA VETA AVE STE 730
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORANGE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92868-4229
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-541-6800
Provider Business Practice Location Address Fax Number:
714-541-1591
Provider Enumeration Date:
03/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CARMONA
Authorized Official First Name:
ELSA
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
714-541-6800

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , 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)





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