Provider Demographics
NPI:1225690332
Name:ALSOUBAII, MOHAMED BOURAHI
Entity Type:Individual
Prefix:
First Name:MOHAMED
Middle Name:BOURAHI
Last Name:ALSOUBAII
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3302 EAGLE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85650-6636
Mailing Address - Country:US
Mailing Address - Phone:602-303-0819
Mailing Address - Fax:
Practice Address - Street 1:2021 N PAN AMERICAN AVE
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:AZ
Practice Address - Zip Code:85607-1137
Practice Address - Country:US
Practice Address - Phone:602-303-0819
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-28
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9113555343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)