Healthcare Provider Details

I. General information

NPI: 1588400733
Provider Name (Legal Business Name): CLEAN HEART CARDIOLOGY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2024
Last Update Date: 11/22/2024
Certification Date: 11/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 WESTERN AVE STE 302
SAN BERNARDINO CA
92411-1354
US

IV. Provider business mailing address

1800 WESTERN AVE STE 302
SAN BERNARDINO CA
92411-1354
US

V. Phone/Fax

Practice location:
  • Phone: 909-713-2323
  • Fax: 909-340-4421
Mailing address:
  • Phone: 909-713-2323
  • Fax: 909-340-4421

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State

VIII. Authorized Official

Name: SOOD KISRA
Title or Position: PRESIDENT
Credential: MD
Phone: 909-713-2323