Healthcare Provider Details

I. General information

NPI: 1801617527
Provider Name (Legal Business Name): PREM RANDALL SAHGAL JR. REGISTERED NURSE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2024
Last Update Date: 10/24/2024
Certification Date: 10/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1161 E COVINA BLVD
COVINA CA
91724-1523
US

IV. Provider business mailing address

1717 W SHERWAY ST
WEST COVINA CA
91790-2636
US

V. Phone/Fax

Practice location:
  • Phone: 626-859-5277
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number622156
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number622156
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: