1407291347 NPI number — EXECUTIVE MEDICINE, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407291347 NPI number — EXECUTIVE MEDICINE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EXECUTIVE MEDICINE, 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:
1407291347
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/01/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2063
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONROVIA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91017-6063
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-254-4496
Provider Business Mailing Address Fax Number:
877-254-4496

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1227 BUENA VISTA ST
Provider Second Line Business Practice Location Address:
SUITE #F
Provider Business Practice Location Address City Name:
DUARTE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91010-2486
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-254-4496
Provider Business Practice Location Address Fax Number:
877-254-4496
Provider Enumeration Date:
05/06/2013

Additional Information

Authorized Official

Authorized Official Last Name:
SARGEANT
Authorized Official First Name:
ULIN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
877-254-4496

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  A97256 , 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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