Provider Demographics
NPI:1780003012
Name:BADAWIYA, HUSAM ISSA
Entity Type:Individual
Prefix:
First Name:HUSAM
Middle Name:ISSA
Last Name:BADAWIYA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17227 GROVE DR
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-6749
Mailing Address - Country:US
Mailing Address - Phone:951-353-0698
Mailing Address - Fax:
Practice Address - Street 1:17227 GROVE DR
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-6749
Practice Address - Country:US
Practice Address - Phone:951-353-0698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-15
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6PDZ412347C00000X
CA6SJH640347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle