Healthcare Provider Details

I. General information

NPI: 1710534821
Provider Name (Legal Business Name): ALPHA ISCANDARI SANUSI BOCPO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2019
Last Update Date: 08/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1760 CHICAGO AVE STE L21
RIVERSIDE CA
92507-2326
US

IV. Provider business mailing address

1760 CHICAGO AVE STE L21
RIVERSIDE CA
92507-2326
US

V. Phone/Fax

Practice location:
  • Phone: 626-622-3359
  • Fax:
Mailing address:
  • Phone: 626-622-3359
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code222Z00000X
TaxonomyOrthotist
License NumberC51502
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License NumberC51502
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: