1194053900 NPI number — DR. F. SHADAN INC.

Table of content: (NPI 1194053900)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194053900 NPI number — DR. F. SHADAN INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR. F. SHADAN INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194053900
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/07/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
322 PROSPECT STREET
Provider Second Line Business Mailing Address:
APT #5
Provider Business Mailing Address City Name:
LA JOLLA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92037-4657
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-390-7899
Provider Business Mailing Address Fax Number:
858-459-3930

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3652 EUREKA WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
REDDING
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96001-0172
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-243-6811
Provider Business Practice Location Address Fax Number:
530-243-2977
Provider Enumeration Date:
12/07/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SHADAN
Authorized Official First Name:
FARHAD
Authorized Official Middle Name:
FARAJI
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
760-390-7899

Provider Taxonomy Codes

  • Taxonomy code: 173F00000X , with the licence number:  A66488 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)