Provider Demographics
NPI:1598131450
Name:BEVERLY ALLIANCE IPA
Entity Type:Organization
Organization Name:BEVERLY ALLIANCE IPA
Other - Org Name:BEVERLY ALIANZA IPA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KHALID
Authorized Official - Middle Name:
Authorized Official - Last Name:NUR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-495-4392
Mailing Address - Street 1:17215 STUDEBAKER RD STE 331
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-2557
Mailing Address - Country:US
Mailing Address - Phone:714-495-4392
Mailing Address - Fax:
Practice Address - Street 1:17215 STUDEBAKER RD STE 331
Practice Address - Street 2:
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703-2557
Practice Address - Country:US
Practice Address - Phone:714-495-4392
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-14
Last Update Date:2015-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC3776980302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization