Healthcare Provider Details

I. General information

NPI: 1780003012
Provider Name (Legal Business Name): HUSAM ISSA BADAWIYA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2014
Last Update Date: 04/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17227 GROVE DR
RIVERSIDE CA
92503-6749
US

IV. Provider business mailing address

17227 GROVE DR
RIVERSIDE CA
92503-6749
US

V. Phone/Fax

Practice location:
  • Phone: 951-353-0698
  • Fax:
Mailing address:
  • Phone: 951-353-0698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number6PDZ412
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number6SJH640
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: