Provider Demographics
NPI:1679951578
Name:NAHEL AL BOUZ MD A PROFESSIONAL MEDICAL CORP
Entity Type:Organization
Organization Name:NAHEL AL BOUZ MD A PROFESSIONAL MEDICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:NAHEL
Authorized Official - Middle Name:
Authorized Official - Last Name:AL BOUZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-241-3595
Mailing Address - Street 1:671 REDWOOD LN
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-3624
Mailing Address - Country:US
Mailing Address - Phone:516-241-3595
Mailing Address - Fax:
Practice Address - Street 1:811 E 11TH ST STE 203
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4872
Practice Address - Country:US
Practice Address - Phone:909-581-6420
Practice Address - Fax:909-982-2322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-11
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207R00000X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty