=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427786367
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PREMIUM EXTREMITY CARE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2022
-----------------------------------------------------
Last Update Date | 08/09/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 843 E FOOTHILL BLVD
-----------------------------------------------------
City | UPLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91786-4034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-982-1002
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 843 E FOOTHILL BLVD
-----------------------------------------------------
City | UPLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91786-4034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-982-1002
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CEO
-----------------------------------------------------
Name | ALI HEIDARI
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 909-982-1002
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208200000X
-----------------------------------------------------
Taxonomy Name | Plastic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------