=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568770188
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | XTREME CARE AMBULANCE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/16/2010
-----------------------------------------------------
Last Update Date | 11/06/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4636 MISSION GORGE PL STE 103-C
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92120-4151
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-822-2674
-----------------------------------------------------
Fax | 619-255-2590
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4636 MISSION GORGE PL SUITE 103-C
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92120-4151
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-822-2674
-----------------------------------------------------
Fax | 619-255-2590
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/CEO
-----------------------------------------------------
Name | MR. SOUHEIL JAWAD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 619-822-2674
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 3311838
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------