Basic Information
| Provider Information | |||||||||
| NPI: | 1659654986 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROTOTYPES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 831 EAST ARROW HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91767 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093984383 | ||||||||
| FaxNumber: | 9093980127 | ||||||||
| Practice Location | |||||||||
| Address1: | 2555 E. COLORADO BLVD | ||||||||
| Address2: | SUITE 100-101 | ||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6265772543 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2011 | ||||||||
| LastUpdateDate: | 06/28/2013 | ||||||||
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| AuthorizedOfficialLastName: | HAVIG | ||||||||
| AuthorizedOfficialFirstName: | JEFFERY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PSYCHIATRIC NURSE | ||||||||
| AuthorizedOfficialTelephone: | 9093984383 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LVN | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164X00000X | VN240811 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Licensed Vocational Nurse |
No ID Information.