MEDICARE: MR. ASA INGRAM CAS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	5542	CA

General Provider Information

NPI Number	:	1164613733
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ASA INGRAM CAS

Provider Business Mailing Address
First Line	:	565 CHANEY ST
Second Line	:
City	:	LAKE ELSINORE
State	:	CA
Zip	:	92530-2722
Country	:	US
Telephone Number	:	951-674-5354
Fax Number	:	951-674-5227

Provider Business Practice Location Address
First Line	:	2055 N PERRIS BLVD
Second Line	:
City	:	PERRIS
State	:	CA
Zip	:	92571-2509
Country	:	US
Telephone Number	:	951-674-5354
Fax Number	:	951-674-5227

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/07/2007
Last Update Date	:	08/07/2007

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