Healthcare Provider Details

I. General information

NPI: 1154748903
Provider Name (Legal Business Name): SIXTEEN:FIVE GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2014
Last Update Date: 03/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7702 ALDEA AVE
LAKE BALBOA CA
91406-2107
US

IV. Provider business mailing address

7702 ALDEA AVE
LAKE BALBOA CA
91406-2107
US

V. Phone/Fax

Practice location:
  • Phone: 818-599-2737
  • Fax:
Mailing address:
  • Phone: 818-599-2737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State

VIII. Authorized Official

Name: RAYMOND AQUINO MAGSAYSAY JR.
Title or Position: CEO
Credential:
Phone: 818-599-2737