=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477019669
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEDIATRIC CARDIAC CENTER INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2019
-----------------------------------------------------
Last Update Date | 02/13/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 433 DEL NORTE AVE
-----------------------------------------------------
City | YUBA CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95991-4113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-933-2736
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 433 DEL NORTE AVE
-----------------------------------------------------
City | YUBA CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95991-4113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-933-2736
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MD/PRESIDENT
-----------------------------------------------------
Name | IMAN KAHWAJI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 530-933-2736
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2080P0202X
-----------------------------------------------------
Taxonomy Name | Pediatric Cardiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------