Healthcare Provider Details

I. General information

NPI: 1942590351
Provider Name (Legal Business Name): INLAND EMPIRE EXTRA CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2011
Last Update Date: 04/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10841 WHITE OAK AVE SUITE 107
RANCHO CUCAMONGA CA
91730-3811
US

IV. Provider business mailing address

10841 WHITE OAK AVE SUITE 107
RANCHO CUCAMONGA CA
91730-3811
US

V. Phone/Fax

Practice location:
  • Phone: 909-483-8361
  • Fax: 909-483-2070
Mailing address:
  • Phone: 909-483-8361
  • Fax: 909-483-2070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License NumberA48743
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License NumberA48743
License Number StateCA

VIII. Authorized Official

Name: DR. ZAHER AZZAWI
Title or Position: PRESIDENT
Credential: M.D
Phone: 909-483-8361