Provider Demographics
NPI:1386827988
Name:GUSTAFSON ORTHOPEDICS, INC.
Entity Type:Organization
Organization Name:GUSTAFSON ORTHOPEDICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL BILLER
Authorized Official - Prefix:
Authorized Official - First Name:TAMMI
Authorized Official - Middle Name:
Authorized Official - Last Name:ZIOLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-478-5600
Mailing Address - Street 1:PO BOX 1056
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-1056
Mailing Address - Country:US
Mailing Address - Phone:909-478-5600
Mailing Address - Fax:909-478-5601
Practice Address - Street 1:10459 MT VIEW AVE
Practice Address - Street 2:STE. B
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-2033
Practice Address - Country:US
Practice Address - Phone:909-478-5600
Practice Address - Fax:909-478-5601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-06
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG24086174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ28798ZOtherMEDICARE PROVIDER #
CA00G240860Medicaid