Healthcare Provider Details

I. General information

NPI: 1073962171
Provider Name (Legal Business Name): FARIED BANIMAHD MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2016
Last Update Date: 01/10/2020
Certification Date: 01/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1533 E 4TH ST STE 4
SANTA ANA CA
92701-5115
US

IV. Provider business mailing address

1835 NEWPORT BLVD STE A109-559
COSTA MESA CA
92627-5031
US

V. Phone/Fax

Practice location:
  • Phone: 949-347-8721
  • Fax: 949-347-8709
Mailing address:
  • Phone: 949-347-8721
  • Fax: 949-347-8709

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. FARIED BANIMAHD
Title or Position: CHIEF MEDICAL AND EXECUTIVE OFFICER
Credential: MD
Phone: 949-305-8910