Healthcare Provider Details

I. General information

NPI: 1043661457
Provider Name (Legal Business Name): HANI CHAABO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2016
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 N CHINA LAKE BLVD STE 190
RIDGECREST CA
93555-3131
US

IV. Provider business mailing address

316 W FELSPAR AVE
RIDGECREST CA
93555-3554
US

V. Phone/Fax

Practice location:
  • Phone: 760-499-3855
  • Fax: 760-499-3870
Mailing address:
  • Phone: 304-550-5698
  • Fax: 866-305-3569

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code202D00000X
TaxonomyIntegrative Medicine Physician
License NumberA159757
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA159757
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA159757
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: