Healthcare Provider Details

I. General information

NPI: 1659701787
Provider Name (Legal Business Name): MAICENNA MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2013
Last Update Date: 11/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8504 FIRESTONE BLVD SUITE 271
DOWNEY CA
90241-4926
US

IV. Provider business mailing address

8504 FIRESTONE BLVD SUITE 271
DOWNEY CA
90241-4926
US

V. Phone/Fax

Practice location:
  • Phone: 310-702-6007
  • Fax: 773-494-2174
Mailing address:
  • Phone: 310-702-6007
  • Fax: 773-494-2174

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A12379
License Number StateCA

VIII. Authorized Official

Name: DR. BEHZAD SOUFERZADEH
Title or Position: GENERAL PARTNER/PROVIDER
Credential: MD
Phone: 310-702-6007