1326014705 NPI number — MRS. RENEE GAYNELL BRADLEY PORTER LVN RAC-C

Table of content: MRS. RENEE GAYNELL BRADLEY PORTER LVN RAC-C (NPI 1326014705)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326014705 NPI number — MRS. RENEE GAYNELL BRADLEY PORTER LVN RAC-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRADLEY PORTER
Provider First Name:
RENEE
Provider Middle Name:
GAYNELL
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LVN RAC-C
Provider Gender Code:
F

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:
1326014705
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
649 EAST 99TH STREET #4
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INGLEWOOD
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90301-6524
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-259-5789
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
301 CENTINELA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INGLEWOOD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90302-3293
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-672-1012
Provider Business Practice Location Address Fax Number:
310-672-5587
Provider Enumeration Date:
02/27/2006

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: 164X00000X , with the licence number:  VN183446 , 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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