Provider Demographics
NPI:1144565805
Name:SOUTHERN CALIFORNIA ASSOCIATED NEUROLOGISTS IPA INC
Entity Type:Organization
Organization Name:SOUTHERN CALIFORNIA ASSOCIATED NEUROLOGISTS IPA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BHUPAT
Authorized Official - Middle Name:
Authorized Official - Last Name:DESAI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-982-2719
Mailing Address - Street 1:1330 W COVINA BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-3200
Mailing Address - Country:US
Mailing Address - Phone:909-982-2719
Mailing Address - Fax:909-946-9931
Practice Address - Street 1:1330 W COVINA BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-3200
Practice Address - Country:US
Practice Address - Phone:909-982-2719
Practice Address - Fax:909-946-9931
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-06
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization