=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619597671
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HARRY EISENBACH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/20/2020
-----------------------------------------------------
Last Update Date | 04/20/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9312 SMOKETREE LN
-----------------------------------------------------
City | VILLA PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92861-1011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-236-6587
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9312 SMOKETREE LN
-----------------------------------------------------
City | VILLA PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92861-1011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-236-6587
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QA0505X
-----------------------------------------------------
Taxonomy Name | Adult Medicine Physician
-----------------------------------------------------
License Number | A30600
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------