Basic Information
Provider Information | |||||||||
NPI: | 1417965559 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PRIME HEALTHCARE LA PALMA, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LA PALMA INTERCOMMUNITY HOSPITAL | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3300 E. GUASTI ROAD | ||||||||
Address2: |   | ||||||||
City: | ONTARIO | ||||||||
State: | CA | ||||||||
PostalCode: | 917618654 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9092354400 | ||||||||
FaxNumber: | 9092354316 | ||||||||
Practice Location | |||||||||
Address1: | 7901 WALKER STREET | ||||||||
Address2: |   | ||||||||
City: | LA PALMA | ||||||||
State: | CA | ||||||||
PostalCode: | 906231722 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7146707400 | ||||||||
FaxNumber: | 7142296813 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/04/2006 | ||||||||
LastUpdateDate: | 12/23/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | REDDY | ||||||||
AuthorizedOfficialFirstName: | PREM | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHAIRMAN/PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 9092354400 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X |   |   | N |   | Hospitals | General Acute Care Hospital |   | 282N00000X | 060000136 | CA | Y |   | Hospitals | General Acute Care Hospital |   |
No ID Information.