Healthcare Provider Details

I. General information

NPI: 1538576806
Provider Name (Legal Business Name): GERIATRIX, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2014
Last Update Date: 07/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 N LAKE AVE SUITE 800
PASADENA CA
91101-1849
US

IV. Provider business mailing address

155 N LAKE AVE SUITE 800
PASADENA CA
91101-1849
US

V. Phone/Fax

Practice location:
  • Phone: 714-461-1419
  • Fax:
Mailing address:
  • Phone: 714-461-1419
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4941
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number15421
License Number StateCA

VIII. Authorized Official

Name: MS. ESTELEI A PENULIAR
Title or Position: PRESIDENT
Credential: NP
Phone: 714-461-1419