Healthcare Provider Details

I. General information

NPI: 1649428087
Provider Name (Legal Business Name): SOUTHERN CALIFORNIA ANESTHESIA PROVIDERS SCAP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2008
Last Update Date: 11/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1809 VERDUGO BLVD STE 140
GLENDALE CA
91208-1402
US

IV. Provider business mailing address

210 N TUSTIN AVE
SANTA ANA CA
92705-3807
US

V. Phone/Fax

Practice location:
  • Phone: 818-790-7874
  • Fax:
Mailing address:
  • Phone: 800-883-7243
  • Fax: 714-647-1245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number20A9369
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number20A9369
License Number StateCA

VIII. Authorized Official

Name: DR. ALI NASSIRI
Title or Position: PRESIDENT
Credential: D.O.
Phone: 800-883-7243