Basic Information
| Provider Information | |||||||||
| NPI: | 1871827931 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COMMODORE | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LVN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9410 OLIVE ST | ||||||||
| Address2: | |||||||||
| City: | BELLFLOWER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907064516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5623262218 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11741 TELEGRAPH RD | ||||||||
| Address2: | STE G-H | ||||||||
| City: | SANTA FE SPRINGS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906703681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6262545000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2009 | ||||||||
| LastUpdateDate: | 09/22/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164X00000X | VN199852 | CA | Y | Nursing Service Providers | Licensed Vocational Nurse |
ID Information
| ID | Type | State | Issuer | Description | 164X00000X | 01 | CA | NONE | OTHER |