Healthcare Provider Details

I. General information

NPI: 1104532308
Provider Name (Legal Business Name): MR. AFSHIN MIRBOLOOKI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2023
Last Update Date: 03/04/2023
Certification Date: 03/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3610 CENTRAL AVE STE 400
RIVERSIDE CA
92506-5907
US

IV. Provider business mailing address

3610 CENTRAL AVE STE 400
RIVERSIDE CA
92506-5907
US

V. Phone/Fax

Practice location:
  • Phone: 951-899-0048
  • Fax: 951-900-1614
Mailing address:
  • Phone: 951-899-0048
  • Fax: 951-900-1614

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: