=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477100378
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED CARE ORTHOPEDICS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/25/2019
-----------------------------------------------------
Last Update Date | 05/24/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4067 TWEEDY BLVD
-----------------------------------------------------
City | SOUTH GATE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90280-6146
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-569-1126
-----------------------------------------------------
Fax | 877-403-7113
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16215 WAYFARER LN
-----------------------------------------------------
City | HUNTINGTON BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92649-2149
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-595-2248
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. SHAFAGH MONAZZAM
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 323-569-1126
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------