Healthcare Provider Details

I. General information

NPI: 1558905950
Provider Name (Legal Business Name): SHAHIN ADAM BAVARSAD BA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2019
Last Update Date: 10/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6809 INDIANA AVE
RIVERSIDE CA
92506-4221
US

IV. Provider business mailing address

10154 ASHFORD ST
RANCHO CUCAMONGA CA
91730-3001
US

V. Phone/Fax

Practice location:
  • Phone: 866-823-4283
  • Fax: 475-235-3169
Mailing address:
  • Phone: 562-507-6861
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: