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General NPI Number Information
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NPI Number | 1871841692
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Entity Type | Organization
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Legal Business Name | MMJ MEDICAL INC,
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Dates
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Enumeration Date | 08/28/2012
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Last Update Date | 11/16/2012
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Provider Practice Location Address
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Address Line | 1810 FULLERTON AVE SUITE 203
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City | CORONA
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State | CA
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Zip | 92881
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Country | US
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Telephone | 951-934-0505
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Fax | 951-934-0506
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Provider Business Mailing Address
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Address Line | 29 PRAIRIE
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City | IRVINE
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State | CA
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Zip | 92618-8840
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Country | US
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Telephone | 949-825-5188
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Fax | 949-825-5189
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Authorized Official
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Title or Position | OWNER
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Name | DR. MOHAMMAD MAZEN JAMAL
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Credential | M.D/MPH
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Telephone | 949-813-5115
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RG0100X
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Taxonomy Name | Gastroenterology Physician
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License Number | A46078
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License Number State | CA
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