=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306032099
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALIED FIVE STAR CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/17/2007
-----------------------------------------------------
Last Update Date | 09/17/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7365 CARNELIAN ST STE 124
-----------------------------------------------------
City | RANCHO CUCAMONGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91730-1156
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-948-2080
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7365 CARNELIAN ST STE 124
-----------------------------------------------------
City | RANCHO CUCAMONGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91730-1156
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SURAIYA AHMED
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 909-948-2080
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | PT15373
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------