Healthcare Provider Details

I. General information

NPI: 1750564043
Provider Name (Legal Business Name): AWESOME BLESSINGS MEDICAL CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2007
Last Update Date: 04/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

595 ESTUDILLO AVE
SAN LEANDRO CA
94577-4611
US

IV. Provider business mailing address

595 ESTUDILLO AVE
SAN LEANDRO CA
94577-4611
US

V. Phone/Fax

Practice location:
  • Phone: 510-483-5881
  • Fax: 510-483-7114
Mailing address:
  • Phone: 510-483-5881
  • Fax: 510-483-7114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberA53206
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberA53206
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License NumberA53206
License Number StateCA

VIII. Authorized Official

Name: DR. THAN AYE AW
Title or Position: OWNER
Credential: M.D
Phone: 559-905-9087