Healthcare Provider Details

I. General information

NPI: 1679951578
Provider Name (Legal Business Name): NAHEL AL BOUZ MD A PROFESSIONAL MEDICAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2015
Last Update Date: 10/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 E 11TH ST STE 203
UPLAND CA
91786-4872
US

IV. Provider business mailing address

671 REDWOOD LN
SAN DIMAS CA
91773-3624
US

V. Phone/Fax

Practice location:
  • Phone: 909-581-6420
  • Fax: 909-982-2322
Mailing address:
  • Phone: 516-241-3595
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number StateCA

VIII. Authorized Official

Name: DR. NAHEL AL BOUZ
Title or Position: CEO
Credential: M.D.
Phone: 516-241-3595