1124039029 NPI number — WENNEKER & LOFTUS INC

Table of content: (NPI 1124039029)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124039029 NPI number — WENNEKER & LOFTUS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WENNEKER & LOFTUS 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:
SURGERY GROUP OF NAPA VALLEY
Provider Other Organization Name Type Code:
3
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:
1124039029
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/22/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3443 VILLA LANE
Provider Second Line Business Mailing Address:
SUITE 5
Provider Business Mailing Address City Name:
NAPA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94558-6417
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-226-2034
Provider Business Mailing Address Fax Number:
707-252-1087

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3443 VILLA LANE
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
NAPA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94558-6417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-226-2034
Provider Business Practice Location Address Fax Number:
707-252-1087
Provider Enumeration Date:
08/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RIOS
Authorized Official First Name:
SASHA
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
707-226-2031

Provider Taxonomy Codes

  • Taxonomy code: 208600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2086S0129X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086X0206X , with the licence number: C529280 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: GR0083940 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZ55854Z . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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