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General NPI Number Information
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NPI Number | 1912406794
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Entity Type | Organization
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Legal Business Name | SO CAL MIWLS INSTITUTE INC
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Dates
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Enumeration Date | 02/07/2018
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Last Update Date | 02/07/2018
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Provider Practice Location Address
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Address Line | 627 W AVENUE Q STE A
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City | PALMDALE
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State | CA
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Zip | 93551-3891
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Country | US
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Telephone | 661-723-7833
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Fax | 877-723-1502
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Provider Business Mailing Address
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Address Line | 627 W AVENUE Q STE A
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City | PALMDALE
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State | CA
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Zip | 93551-3891
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Country | US
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Telephone | 661-723-7833
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Fax | 877-723-1502
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Authorized Official
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Title or Position | PRESIDENT
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Name | JOHN YADEGAR
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Credential | MD
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Telephone | 310-995-9600
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | A87209
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License Number State | CA
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