Basic Information
Provider Information | |||||||||
NPI: | 1669803003 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ADVENTIST HEALTH PHYSICIANS NETWORK | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1530 E CHEVY CHASE DR STE 110 | ||||||||
Address2: |   | ||||||||
City: | GLENDALE | ||||||||
State: | CA | ||||||||
PostalCode: | 912064139 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8182655411 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2256 DOCKERY AVE | ||||||||
Address2: | SUITE #B | ||||||||
City: | SELMA | ||||||||
State: | CA | ||||||||
PostalCode: | 936623873 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5598566170 | ||||||||
FaxNumber: | 5598566172 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/11/2013 | ||||||||
LastUpdateDate: | 11/27/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SERNA | ||||||||
AuthorizedOfficialFirstName: | ADRIAN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | C.F.O | ||||||||
AuthorizedOfficialTelephone: | 9168651865 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
No ID Information.