Provider Demographics
NPI:1396166567
Name:PLASMAGENIX MEDICAL CORP
Entity type:Organization
Organization Name:PLASMAGENIX MEDICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MRS
Authorized Official - First Name:ARTENCIA
Authorized Official - Middle Name:
Authorized Official - Last Name:GARRETT
Authorized Official - Suffix:
Authorized Official - Credentials:CMA, EMT-P
Authorized Official - Phone:323-810-0742
Mailing Address - Street 1:455 N PRAIRIE AVE
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-1413
Mailing Address - Country:US
Mailing Address - Phone:310-412-0183
Mailing Address - Fax:310-412-0015
Practice Address - Street 1:455 N PRAIRIE AVE
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-1413
Practice Address - Country:US
Practice Address - Phone:310-412-0183
Practice Address - Fax:310-412-0015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-13
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA100364261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
E3630Medicare PIN
GA537ZMedicare PIN