=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386028629
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BAJWA ENTERPRISES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/16/2015
-----------------------------------------------------
Last Update Date | 07/16/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 30200 AGOURA RD STE 150
-----------------------------------------------------
City | AGOURA HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91301-5427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-278-1450
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 30200 AGOURA RD STE 150
-----------------------------------------------------
City | AGOURA HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91301-5427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-278-1450
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MANDEEP BAJWA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 805-278-1450
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------