Healthcare Provider Details

I. General information

NPI: 1477952117
Provider Name (Legal Business Name): LIBRA PAIN CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2014
Last Update Date: 02/04/2026
Certification Date: 02/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1433 W MERCED AVE STE 103
WEST COVINA CA
91790-3402
US

IV. Provider business mailing address

1433 W MERCED AVE STE 103
WEST COVINA CA
91790-3402
US

V. Phone/Fax

Practice location:
  • Phone: 626-506-2648
  • Fax: 626-898-9250
Mailing address:
  • Phone: 626-506-2648
  • Fax: 626-898-9250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA126658
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License NumberA126658
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberA126658
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberA126658
License Number StateCA

VIII. Authorized Official

Name: DR. SAM AHDAB
Title or Position: PRESIDENT
Credential: M.D.
Phone: 323-217-2856