1992162911 NPI number — GORDIAN MEDICAL IV, INC.

Table of content: (NPI 1992162911)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992162911 NPI number — GORDIAN MEDICAL IV, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GORDIAN MEDICAL IV, 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:
1992162911
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/03/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
750 THE CITY DR S STE 225
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:
92868-4976
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-556-0200
Provider Business Mailing Address Fax Number:
877-380-8282

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3610 CENTRAL AVE, FLOOR 4 SUITE 40
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIVERSIDE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92506-5900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-736-9000
Provider Business Practice Location Address Fax Number:
877-380-8282
Provider Enumeration Date:
01/21/2016

Additional Information

Authorized Official

Authorized Official Last Name:
BOWMAN
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
714-556-0200

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1992162911 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1992162911 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1992162911 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 246478 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1992162911 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 59557206 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0228912 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 092120 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1992162911 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 250016853 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10026672800 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1221084 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1992162911 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200711680A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 201159940A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 05171664 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1992162911 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1992162911 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 500775991 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 08724809 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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