Basic Information
| Provider Information | |||||||||
| NPI: | 1821467937 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CEP-AMERICA, OSA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 26871 ALESSANDRO BLVD | ||||||||
| Address2: | SPACE 35 | ||||||||
| City: | MORENO VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925553903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7606109362 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 400 N PEPPER AVE | ||||||||
| Address2: | SUITE 107 | ||||||||
| City: | COLTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923241801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095804289 | ||||||||
| FaxNumber: | 9095801388 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2015 | ||||||||
| LastUpdateDate: | 09/18/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SIVA | ||||||||
| AuthorizedOfficialFirstName: | NICOLE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EMPA FELLOWSHIP COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 9095804289 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
No ID Information.