=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396124293
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FOAD ELAHI MD CALIFORNIA CENTER OF PAIN MEDICINE AND REHABILITATION I
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/26/2015
-----------------------------------------------------
Last Update Date | 07/29/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1144 NORMAN DR 104
-----------------------------------------------------
City | MANTECA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95336-5925
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-824-4400
-----------------------------------------------------
Fax | 209-824-4420
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1144 NORMAN DR 104
-----------------------------------------------------
City | MANTECA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95336-5925
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-824-4400
-----------------------------------------------------
Fax | 209-824-4420
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FOUNDER
-----------------------------------------------------
Name | DR. FOAD ELAHI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 312-863-9377
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2081P2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Physical Medicine & Rehabilitation) Physician
-----------------------------------------------------
License Number | A106279
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------