=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871940171
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAN AN, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2016
-----------------------------------------------------
Last Update Date | 05/17/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4909 NE 28TH ST
-----------------------------------------------------
City | HALTOM CITY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76117-4412
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-831-3237
-----------------------------------------------------
Fax | 817-831-3235
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4909 NE 28TH ST
-----------------------------------------------------
City | HALTOM CITY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76117-4412
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-831-3237
-----------------------------------------------------
Fax | 817-831-3235
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. MOHAMMED AHMED HASSAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 817-353-3000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 347C00000X
-----------------------------------------------------
Taxonomy Name | Private Vehicle
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------