=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275040008
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GM SURGICAL ASSISTANT INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/02/2018
-----------------------------------------------------
Last Update Date | 01/02/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15615 TURNBERRY ST
-----------------------------------------------------
City | MORENO VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92555-4901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-992-6201
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15615 TURNBERRY ST
-----------------------------------------------------
City | MORENO VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92555-4901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-992-6201
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING ADMIN
-----------------------------------------------------
Name | JENNIFER SEVILLA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 909-346-0807
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number | PA22985
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------