Individual
Inactive
Individual
Inactive
Sole proprietor
Provider details
NPI number
Taxonomy
Speciality
Code
Description
License number
State
251K00000X
Public Health or Welfare Agency
Primary
—
—
261QP0904X
Federal Public Health Clinic/Center
—
—
261QP0905X
State or Local Public Health Clinic/Center
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2302
MEDI-CAL #
CA
Enumeration date
—
Last updated
—
Update your record
If you believe information in your NPPES record is inaccurate, or if you wish to update or deactivate your NPI, you can do so directly with CMS at https://nppes.cms.hhs.gov.
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