MEDICARE: MR. MOHAMED ADE NOOR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172A00000X	Driver
2	343900000X	Non-emergency Medical Transport (VAN)	D9575542	CA

General Provider Information

NPI Number	:	1134786817
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MOHAMED ADE NOOR

Provider Business Mailing Address
First Line	:	3774 GROVE ST STE L2
Second Line	:
City	:	LEMON GROVE
State	:	CA
Zip	:	91945-1899
Country	:	US
Telephone Number	:	619-863-3954
Fax Number	:

Provider Business Practice Location Address
First Line	:	9258 KENWOOD DR APT D
Second Line	:
City	:	SPRING VALLEY
State	:	CA
Zip	:	91977-2328
Country	:	US
Telephone Number	:	619-863-3954
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/28/2019
Last Update Date	:	11/27/2019

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