Provider Demographics
NPI:1154634228
Name:NOVA MEDICAL CENTER, A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:NOVA MEDICAL CENTER, A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:
Authorized Official - Last Name:CALDRON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-599-1002
Mailing Address - Street 1:1197 E LOS ANGELES AVE STE C303
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-2868
Mailing Address - Country:US
Mailing Address - Phone:805-501-6685
Mailing Address - Fax:866-472-9836
Practice Address - Street 1:1423 W 8TH ST
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-3803
Practice Address - Country:US
Practice Address - Phone:818-599-1002
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NOVA MEDICAL CENTER, A PROFESSIONAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-07-19
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site