Healthcare Provider Details

I. General information

NPI: 1609112697
Provider Name (Legal Business Name): CAROL R BAHARI RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2012
Last Update Date: 12/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11611 ARROYO AVE
SANTA ANA CA
92705-3002
US

IV. Provider business mailing address

11611 ARROYO AVE
SANTA ANA CA
92705-3002
US

V. Phone/Fax

Practice location:
  • Phone: 714-269-5990
  • Fax:
Mailing address:
  • Phone: 714-269-5990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number389901
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: