Provider Demographics
NPI:1326571688
Name:HAM, MARY LOU
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LOU
Last Name:HAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3602 KURTZ ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-4432
Mailing Address - Country:US
Mailing Address - Phone:619-448-4444
Mailing Address - Fax:619-550-1089
Practice Address - Street 1:3602 KURTZ ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-4432
Practice Address - Country:US
Practice Address - Phone:619-448-4444
Practice Address - Fax:619-550-1089
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-04
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB2000013593343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)