=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144557539
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | I HENAWI MD INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2009
-----------------------------------------------------
Last Update Date | 06/11/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4020 W FLORIDA AVE
-----------------------------------------------------
City | HEMET
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92545-5279
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-765-5000
-----------------------------------------------------
Fax | 951-658-0237
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4020 W FLORIDA AVE
-----------------------------------------------------
City | HEMET
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92545-5279
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-765-5000
-----------------------------------------------------
Fax | 951-658-0237
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. I HENAWI
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 951-765-5000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | A62143
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------