1396873964 NPI number — COMPREHENSIVE CARE CLINIC MEDICAL CORPORATION

Table of content: (NPI 1396873964)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396873964 NPI number — COMPREHENSIVE CARE CLINIC MEDICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMPREHENSIVE CARE CLINIC MEDICAL CORPORATION
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:
1396873964
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/10/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2615 H ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BAKERSFIELD
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93301-2819
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
661-665-8656
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2615 H ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BAKERSFIELD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93301-2819
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
661-665-8656
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PATEL
Authorized Official First Name:
RAJU
Authorized Official Middle Name:
B
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
661-635-3000

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  00A632290 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 00A512800 , 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)

  • Identifier: 00A512800 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00A632290 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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