1497769731 NPI number — MARIAM AMIRI

Table of content: (NPI 1497769731)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497769731 NPI number — MARIAM AMIRI

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARIAM AMIRI
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:
6
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:
1497769731
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/24/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1059
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOMA LINDA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92354-1059
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-796-3707
Provider Business Mailing Address Fax Number:
909-796-3709

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11332 MOUNTAIN VIEW AVE
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
LOMA LINDA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92354-3854
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-796-3707
Provider Business Practice Location Address Fax Number:
909-796-3709
Provider Enumeration Date:
07/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
AMIRI
Authorized Official First Name:
MARIAM
Authorized Official Middle Name:
SHANAZ
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
909-796-3707

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  E4049 , 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: GRE001750 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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