=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669923546
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROSAMOND MEDICAL CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2016
-----------------------------------------------------
Last Update Date | 10/17/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1415 W ROSAMOND BLVD #24
-----------------------------------------------------
City | ROSAMOND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93560-7429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-772-8503
-----------------------------------------------------
Fax | 559-772-8504
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 41019 WOODSHIRE DR
-----------------------------------------------------
City | PALMDALE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93551-5746
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-772-8503
-----------------------------------------------------
Fax | 559-772-8504
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ASHMEAD ALI
-----------------------------------------------------
Credential | M.D
-----------------------------------------------------
Telephone | 559-772-8503
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | G078625
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------