Provider Demographics
NPI:1124612775
Name:ATLAS19 LLC
Entity type:Organization
Organization Name:ATLAS19 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:WESTON
Authorized Official - Middle Name:
Authorized Official - Last Name:SUH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-628-8008
Mailing Address - Street 1:2275 HUNTINGTON DR # 314
Mailing Address - Street 2:
Mailing Address - City:SAN MARINO
Mailing Address - State:CA
Mailing Address - Zip Code:91108-2640
Mailing Address - Country:US
Mailing Address - Phone:626-628-8008
Mailing Address - Fax:
Practice Address - Street 1:100 S SAN GABRIEL BLVD
Practice Address - Street 2:
Practice Address - City:SAN GABRIEL
Practice Address - State:CA
Practice Address - Zip Code:91776-1645
Practice Address - Country:US
Practice Address - Phone:626-628-8008
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-24
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center