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General NPI Number Information
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NPI Number | 1659701787
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Entity Type | Organization
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Legal Business Name | MAICENNA MEDICAL GROUP
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Dates
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Enumeration Date | 11/27/2013
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Last Update Date | 11/27/2013
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Provider Practice Location Address
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Address Line | 8504 FIRESTONE BLVD SUITE 271
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City | DOWNEY
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State | CA
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Zip | 90241-4926
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Country | US
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Telephone | 310-702-6007
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Fax | 773-494-2174
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Provider Business Mailing Address
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Address Line | 8504 FIRESTONE BLVD SUITE 271
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City | DOWNEY
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State | CA
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Zip | 90241-4926
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Country | US
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Telephone | 310-702-6007
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Fax | 773-494-2174
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Authorized Official
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Title or Position | GENERAL PARTNER/PROVIDER
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Name | DR. BEHZAD SOUFERZADEH
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Credential | MD
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Telephone | 310-702-6007
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 20A12379
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License Number State | CA
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