1679951578 NPI number — NAHEL AL BOUZ MD A PROFESSIONAL MEDICAL CORP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679951578 NPI number — NAHEL AL BOUZ MD A PROFESSIONAL MEDICAL CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NAHEL AL BOUZ MD A PROFESSIONAL MEDICAL CORP
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:
1679951578
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/31/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
671 REDWOOD LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN DIMAS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91773-3624
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-241-3595
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
811 E 11TH ST STE 203
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
UPLAND
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91786-4872
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-581-6420
Provider Business Practice Location Address Fax Number:
909-982-2322
Provider Enumeration Date:
05/11/2015

Additional Information

Authorized Official

Authorized Official Last Name:
AL BOUZ
Authorized Official First Name:
NAHEL
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
516-241-3595

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , 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)





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