=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750017422
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | A&E PROFESSIONAL MEDICAL GROUP AND NURSING CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2022
-----------------------------------------------------
Last Update Date | 08/03/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6816 PACIFIC BLVD STE 210
-----------------------------------------------------
City | HUNTINGTON PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90255-4654
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-754-7986
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6816 PACIFIC BLVD SUITE 210
-----------------------------------------------------
City | HUNTINGTON PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90255-4654
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-754-7986
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SECRETARY
-----------------------------------------------------
Name | EDEN DABALUS
-----------------------------------------------------
Credential | NP
-----------------------------------------------------
Telephone | 310-848-8865
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------