Provider Demographics
NPI:1710534821
Name:SANUSI, ALPHA ISCANDARI (BOCPO)
Entity Type:Individual
Prefix:
First Name:ALPHA
Middle Name:ISCANDARI
Last Name:SANUSI
Suffix:
Gender:M
Credentials:BOCPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1760 CHICAGO AVE STE L21
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-2326
Mailing Address - Country:US
Mailing Address - Phone:626-622-3359
Mailing Address - Fax:
Practice Address - Street 1:1760 CHICAGO AVE STE L21
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-2326
Practice Address - Country:US
Practice Address - Phone:626-622-3359
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-22
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC51502222Z00000X, 224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC51502OtherORTHOTIST/PROSTHETIST CREDENTIAL