Healthcare Provider Details

I. General information

NPI: 1124265954
Provider Name (Legal Business Name): BIOSTEM,INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2009
Last Update Date: 01/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 LONG BEACH BVLD SUITE 226
LONG BEACH CA
90807
US

IV. Provider business mailing address

14111 FREEWAY DR STE 312
SANTA FE SPRINGS CA
90670-5822
US

V. Phone/Fax

Practice location:
  • Phone: 866-894-7195
  • Fax:
Mailing address:
  • Phone: 866-894-7195
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License NumberRAML 2236-36
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License NumberRAML 1258-19
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code2471N0900X
TaxonomyNuclear Medicine Technology Radiologic Technologist
License NumberRHN 2003
License Number StateCA

VIII. Authorized Official

Name: STEPHENSON O BAMIDELE
Title or Position: CEO
Credential:
Phone: 866-894-7195