Healthcare Provider Details

I. General information

NPI: 1124889019
Provider Name (Legal Business Name): TARIQ AFANDI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2024
Last Update Date: 01/18/2024
Certification Date: 01/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3317 W BEVERLY BLVD
MONTEBELLO CA
90640-1570
US

IV. Provider business mailing address

12611 ARTESIA BLVD APT 340
CERRITOS CA
90703-8694
US

V. Phone/Fax

Practice location:
  • Phone: 323-621-6700
  • Fax:
Mailing address:
  • Phone: 310-956-7631
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number713882
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: