1144450057 NPI number — GLORIA ARLENE LOPEZ-GLASS PA-C

Table of content: MR. DANIEL POLK JR. RRT (NPI 1801236294)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144450057 NPI number — GLORIA ARLENE LOPEZ-GLASS PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LOPEZ-GLASS
Provider First Name:
GLORIA
Provider Middle Name:
ARLENE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LOPEZ-GLASS
Provider Other First Name:
ARLENE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1144450057
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/24/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17412 VENTURA BLVD
Provider Second Line Business Mailing Address:
550
Provider Business Mailing Address City Name:
ENCINO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91316-3827
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17412 VENTURA BLVD
Provider Second Line Business Practice Location Address:
550
Provider Business Practice Location Address City Name:
ENCINO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91316-3827
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-385-9912
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/27/2009

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: 363AM0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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