=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043705718
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FOLSOM LAKE PRIMARY CARE PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/26/2018
-----------------------------------------------------
Last Update Date | 06/26/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2575 E BIDWELL ST STE 210
-----------------------------------------------------
City | FOLSOM
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95630-6446
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-984-7850
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 271 AMERICAN RIVER CANYON DR
-----------------------------------------------------
City | FOLSOM
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95630-7143
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | HADI FIROZ
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 916-790-0450
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | C56218
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------