Provider Demographics
NPI:1104016468
Name:ALAV MEDICAL CORPORATION
Entity Type:Organization
Organization Name:ALAV MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FARAMARZ
Authorized Official - Middle Name:
Authorized Official - Last Name:ALAV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-261-8082
Mailing Address - Street 1:16465 SIERRA LAKES PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-1242
Mailing Address - Country:US
Mailing Address - Phone:909-429-2404
Mailing Address - Fax:909-261-8082
Practice Address - Street 1:16465 SIERRA LAKES PKWY
Practice Address - Street 2:STE 220
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-1242
Practice Address - Country:US
Practice Address - Phone:909-434-1123
Practice Address - Fax:909-261-8082
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-01
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA74033207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH42674Medicare UPIN