Provider Demographics
NPI:1932256211
Name:SOUTH COAST ALLERGY & ASTHMA MEDICAL CORPORATION.
Entity type:Organization
Organization Name:SOUTH COAST ALLERGY & ASTHMA MEDICAL CORPORATION.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CARMELLA
Authorized Official - Middle Name:M
Authorized Official - Last Name:AMAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-245-8645
Mailing Address - Street 1:12370 HESPERIA RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-7719
Mailing Address - Country:US
Mailing Address - Phone:760-245-8645
Mailing Address - Fax:760-245-6798
Practice Address - Street 1:12370 HESPERIA RD
Practice Address - Street 2:SUITE 1
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-7719
Practice Address - Country:US
Practice Address - Phone:760-245-8645
Practice Address - Fax:760-245-6798
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G644932OtherINDIVIDUAL PTAN
CA1922065788OtherNPI INDIVIDUAL
CA030003304OtherRAILROAD MEDICARE
CA1932256211OtherNPI GROUP
CAZZZ53231ZOtherBLUE SHIELD
CA2112929Medicaid
CABD090ZOtherGRP PTAN
CA00G644932OtherINDIVIDUAL PTAN
CA1922065788OtherNPI INDIVIDUAL
CA1932256211OtherNPI GROUP