1508473034 NPI number — ST HUERTA FOUR SQUARE CLINICALS PROFESSIONAL CORPORATION

Table of content: (NPI 1508473034)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508473034 NPI number — ST HUERTA FOUR SQUARE CLINICALS PROFESSIONAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST HUERTA FOUR SQUARE CLINICALS PROFESSIONAL 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:
FOUR SQUARE CLINICALS
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:
1508473034
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/18/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
650 N ROSE DR STE 472
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLACENTIA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92870-7513
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-345-6944
Provider Business Mailing Address Fax Number:
844-872-5607

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 N ARLINGTON AVE STE 340A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RENO
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89501-1248
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
775-238-3082
Provider Business Practice Location Address Fax Number:
844-872-5607
Provider Enumeration Date:
09/29/2020

Additional Information

Authorized Official

Authorized Official Last Name:
HUERTA
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
THOMAS
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
775-238-3082

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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