Provider Demographics
NPI:1417118282
Name:AEGIS MEDICAL SYSTEMS, INC.
Entity Type:Organization
Organization Name:AEGIS MEDICAL SYSTEMS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COUNSELOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:ILENE
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:909-986-4550
Mailing Address - Street 1:125 W F ST
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91762-3262
Mailing Address - Country:US
Mailing Address - Phone:909-986-4506
Mailing Address - Fax:909-986-4506
Practice Address - Street 1:125 W F ST
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91762-3262
Practice Address - Country:US
Practice Address - Phone:909-986-4506
Practice Address - Fax:909-986-4506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-24
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36-04251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management