Provider Demographics
NPI:1720222953
Name:SOCAL MMA UNLIMITED
Entity Type:Organization
Organization Name:SOCAL MMA UNLIMITED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHNNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:IWABUCCI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-350-0040
Mailing Address - Street 1:8727 RALPH ST
Mailing Address - Street 2:
Mailing Address - City:ROSEMEAD
Mailing Address - State:CA
Mailing Address - Zip Code:91770-1736
Mailing Address - Country:US
Mailing Address - Phone:626-350-0040
Mailing Address - Fax:626-297-6744
Practice Address - Street 1:11020 FINEVIEW ST
Practice Address - Street 2:
Practice Address - City:SOUTH EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91733-2817
Practice Address - Country:US
Practice Address - Phone:626-350-0040
Practice Address - Fax:626-279-6744
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-01
Last Update Date:2009-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343800000XTransportation ServicesSecured Medical Transport (VAN)