Provider Demographics
NPI:1861680712
Name:BIENESTAR MEDICAL CENTER, INC
Entity Type:Organization
Organization Name:BIENESTAR MEDICAL CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MOHAMMAD
Authorized Official - Middle Name:WALID
Authorized Official - Last Name:HASSAN
Authorized Official - Suffix:
Authorized Official - Credentials:BBS
Authorized Official - Phone:714-285-1100
Mailing Address - Street 1:1125 E 17TH ST STE N152
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92701-2215
Mailing Address - Country:US
Mailing Address - Phone:714-285-1100
Mailing Address - Fax:
Practice Address - Street 1:1125 E 17TH ST STE N152
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-2215
Practice Address - Country:US
Practice Address - Phone:714-285-1100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-04
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA81858174400000X
CAA61671174400000X
CAA61324174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA66267Medicaid
CAA61324Medicaid
CAA61671Medicaid
CAA81858Medicaid