1659597458 NPI number — YASER A SLAYYEH M D F A C C A MEDICAL CORPORATION

Table of content: (NPI 1659597458)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659597458 NPI number — YASER A SLAYYEH M D F A C C A MEDICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
YASER A SLAYYEH M D F A C C A MEDICAL CORPORATION
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:
1659597458
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/13/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
399 E HIGHLAND AVE
Provider Second Line Business Mailing Address:
SUITE 215
Provider Business Mailing Address City Name:
SAN BERNARDINO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92404-3808
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-882-3300
Provider Business Mailing Address Fax Number:
909-882-3512

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
399 E HIGHLAND AVE
Provider Second Line Business Practice Location Address:
SUITE 215
Provider Business Practice Location Address City Name:
SAN BERNARDINO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92404-3808
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-882-3300
Provider Business Practice Location Address Fax Number:
909-882-3512
Provider Enumeration Date:
04/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SLAYYEH
Authorized Official First Name:
YASER
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
909-882-3300

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  A56032 , 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)

  • Identifier: A56032 . This is a "STATE LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: DB9077 . This is a "RR MEDICARE GRP ID" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 00A560320 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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