Provider Demographics
NPI:1659654986
Name:PROTOTYPES
Entity Type:Organization
Organization Name:PROTOTYPES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHIATRIC NURSE
Authorized Official - Prefix:
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:
Authorized Official - Last Name:HAVIG
Authorized Official - Suffix:
Authorized Official - Credentials:LVN
Authorized Official - Phone:909-398-4383
Mailing Address - Street 1:831 EAST ARROW HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767
Mailing Address - Country:US
Mailing Address - Phone:909-398-4383
Mailing Address - Fax:909-398-0127
Practice Address - Street 1:2555 E. COLORADO BLVD
Practice Address - Street 2:SUITE 100-101
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91107
Practice Address - Country:US
Practice Address - Phone:626-577-2543
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-22
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN240811164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164X00000XNursing Service ProvidersLicensed Vocational NurseGroup - Multi-Specialty