Healthcare Provider Details

I. General information

NPI: 1134786817
Provider Name (Legal Business Name): MR. MOHAMED ADE NOOR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2019
Last Update Date: 11/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9258 KENWOOD DR APT D
SPRING VALLEY CA
91977-2328
US

IV. Provider business mailing address

3774 GROVE ST STE L2
LEMON GROVE CA
91945-1899
US

V. Phone/Fax

Practice location:
  • Phone: 619-863-3954
  • Fax:
Mailing address:
  • Phone: 619-863-3954
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License NumberD9575542
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: