Healthcare Provider Details

I. General information

NPI: 1154927192
Provider Name (Legal Business Name): 4000 MOUNT ELENA CIRCLE CORONA, CA 92882
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2020
Last Update Date: 12/07/2020
Certification Date: 12/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 MOUNT ELENA CIR
CORONA CA
92882-7916
US

IV. Provider business mailing address

4000 MOUNT ELENA CIR
CORONA CA
92882-7916
US

V. Phone/Fax

Practice location:
  • Phone: 626-993-5823
  • Fax:
Mailing address:
  • Phone: 626-993-5823
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name: ALICE K YOUSSEF
Title or Position: OWNER
Credential:
Phone: 626-993-5823