Healthcare Provider Details

I. General information

NPI: 1669785499
Provider Name (Legal Business Name): HEBA FAKHOURY PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MISS HEBA MAZEN QAQISH

II. Dates (important events)

Enumeration Date: 07/21/2010
Last Update Date: 07/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1780 TOWN AND COUNTRY DR STE 103
NORCO CA
92860-3618
US

IV. Provider business mailing address

PO BOX 579
NORCO CA
92860-0579
US

V. Phone/Fax

Practice location:
  • Phone: 951-270-0757
  • Fax: 951-270-0758
Mailing address:
  • Phone: 951-270-0757
  • Fax: 951-270-0758

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number36168
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: