Provider Demographics
NPI:1942590351
Name:INLAND EMPIRE EXTRA CARE
Entity Type:Organization
Organization Name:INLAND EMPIRE EXTRA CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ZAHER
Authorized Official - Middle Name:
Authorized Official - Last Name:AZZAWI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-483-8361
Mailing Address - Street 1:10841 WHITE OAK AVE
Mailing Address - Street 2:SUITE 107
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-3811
Mailing Address - Country:US
Mailing Address - Phone:909-483-8361
Mailing Address - Fax:909-483-2070
Practice Address - Street 1:10841 WHITE OAK AVE
Practice Address - Street 2:SUITE 107
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3811
Practice Address - Country:US
Practice Address - Phone:909-483-8361
Practice Address - Fax:909-483-2070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-19
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA48743302R00000X, 305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
No305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF51007Medicare UPIN