Provider Demographics
NPI:1134786817
Name:NOOR, MOHAMED ADE
Entity type:Individual
Prefix:MR
First Name:MOHAMED
Middle Name:ADE
Last Name:NOOR
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 1:3774 GROVE ST STE L2
Mailing Address - Street 2:
Mailing Address - City:LEMON GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:91945-1899
Mailing Address - Country:US
Mailing Address - Phone:619-863-3954
Mailing Address - Fax:
Practice Address - Street 1:9258 KENWOOD DR APT D
Practice Address - Street 2:
Practice Address - City:SPRING VALLEY
Practice Address - State:CA
Practice Address - Zip Code:91977-2328
Practice Address - Country:US
Practice Address - Phone:619-863-3954
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-28
Last Update Date:2019-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172A00000X
CAD9575542343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No172A00000XOther Service ProvidersDriver