Provider Demographics
NPI:1689846503
Name:AVA MEDICAL CORPORATION
Entity Type:Organization
Organization Name:AVA MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:HOMA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHOGHIAN-SHABANPOUR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-444-0044
Mailing Address - Street 1:1329 W WARNER AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92704-5118
Mailing Address - Country:US
Mailing Address - Phone:714-444-0044
Mailing Address - Fax:714-444-0043
Practice Address - Street 1:1329 W WARNER AVE
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92704-5118
Practice Address - Country:US
Practice Address - Phone:714-444-0044
Practice Address - Fax:714-444-0043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-01
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA80009261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA80009Medicaid