Provider Demographics
NPI:1972824118
Name:VISITH PRIN MD A PROFESSIONAL CORP
Entity Type:Organization
Organization Name:VISITH PRIN MD A PROFESSIONAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VISITH
Authorized Official - Middle Name:
Authorized Official - Last Name:PRIROMPRINTR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-924-1906
Mailing Address - Street 1:11441 HEACOCK ST STE B1
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92557-7907
Mailing Address - Country:US
Mailing Address - Phone:951-924-1906
Mailing Address - Fax:
Practice Address - Street 1:11441 HEACOCK ST STE B1
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92557-7907
Practice Address - Country:US
Practice Address - Phone:951-924-1906
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-22
Last Update Date:2012-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA40164207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty