1922540293 NPI number — MARCELA TINOCO CLARK

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 1922540293 NPI number — MARCELA TINOCO CLARK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
MARCELA
Provider Middle Name:
TINOCO
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CLARK
Provider Other First Name:
MARCELA
Provider Other Middle Name:
TINOCO
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1922540293
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/06/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
290 IOOF AVE
Provider Second Line Business Mailing Address:
REBEKAH CHILDRENS SERVICES 290 IOOF AVE
Provider Business Mailing Address City Name:
GILROY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95020
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:
290 IOOF AVE
Provider Second Line Business Practice Location Address:
REBEKAH CHILDRENS SERVICES 290 IOOF AVE
Provider Business Practice Location Address City Name:
GILROY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95020
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
408-846-2467
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/17/2016

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: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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