Basic Information
| Provider Information | |||||||||
| NPI: | 1134420201 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH VALLEY HEMATOLOGY/ONCOLOGY MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11100-8 SEPULVEDA BLVD | ||||||||
| Address2: | PMB 575 | ||||||||
| City: | MISSION HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913451101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8184962721 | ||||||||
| FaxNumber: | 8184964126 | ||||||||
| Practice Location | |||||||||
| Address1: | 15031 RINALDI ST | ||||||||
| Address2: | |||||||||
| City: | MISSION HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913451207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8183653099 | ||||||||
| FaxNumber: | 8188371987 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2010 | ||||||||
| LastUpdateDate: | 08/03/2011 | ||||||||
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| AuthorizedOfficialLastName: | ENGLE-BENNETT | ||||||||
| AuthorizedOfficialFirstName: | JULIA | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8184962722 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 1134420201 | 05 | CA | MEDICAID |