Basic Information
Provider Information | |||||||||
NPI: | 1366970154 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MHA VILLAGE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2024 FULLERTON AVE | ||||||||
Address2: |   | ||||||||
City: | COSTA MESA | ||||||||
State: | CA | ||||||||
PostalCode: | 926272105 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6615374772 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 456 ELM AVE | ||||||||
Address2: |   | ||||||||
City: | LONG BEACH | ||||||||
State: | CA | ||||||||
PostalCode: | 908022426 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5624376717 | ||||||||
FaxNumber: | 5624375072 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/24/2017 | ||||||||
LastUpdateDate: | 05/24/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LIMON | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: | RENEE | ||||||||
AuthorizedOfficialTitleorPosition: | STUDENT NURSE | ||||||||
AuthorizedOfficialTelephone: | 6615374772 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251J00000X |   |   | Y |   | Agencies | Nursing Care |   |
No ID Information.