=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598131450
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BEVERLY ALLIANCE IPA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2015
-----------------------------------------------------
Last Update Date | 08/14/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17215 STUDEBAKER RD STE 331
-----------------------------------------------------
City | CERRITOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90703-2557
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-495-4392
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17215 STUDEBAKER RD STE 331
-----------------------------------------------------
City | CERRITOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90703-2557
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-495-4392
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | KHALID NUR
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 714-495-4392
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 302R00000X
-----------------------------------------------------
Taxonomy Name | Health Maintenance Organization
-----------------------------------------------------
License Number | C3776980
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------