Provider Demographics
NPI:1013306307
Name:1958
Entity Type:Organization
Organization Name:1958
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED NURSE
Authorized Official - Prefix:
Authorized Official - First Name:LORAINE
Authorized Official - Middle Name:
Authorized Official - Last Name:POWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-838-4593
Mailing Address - Street 1:9344 NATIONAL BLVD APT 11
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90034-2925
Mailing Address - Country:US
Mailing Address - Phone:619-838-4593
Mailing Address - Fax:
Practice Address - Street 1:730 E CLARK ST
Practice Address - Street 2:#4657
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83205-5401
Practice Address - Country:US
Practice Address - Phone:619-838-4593
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-09
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA728144282NR1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NR1301XHospitalsGeneral Acute Care HospitalRural