Provider Demographics
NPI:1184941494
Name:EXCELLENT ANESTHESIA PC
Entity type:Organization
Organization Name:EXCELLENT ANESTHESIA PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:O
Authorized Official - Last Name:DIMOWO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-966-6626
Mailing Address - Street 1:1260 PIERRE RD
Mailing Address - Street 2:
Mailing Address - City:WALNUT
Mailing Address - State:CA
Mailing Address - Zip Code:91789-1934
Mailing Address - Country:US
Mailing Address - Phone:951-966-6626
Mailing Address - Fax:909-594-6607
Practice Address - Street 1:1260 PIERRE RD
Practice Address - Street 2:
Practice Address - City:WALNUT
Practice Address - State:CA
Practice Address - Zip Code:91789-1934
Practice Address - Country:US
Practice Address - Phone:951-966-6626
Practice Address - Fax:909-594-6607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-26
Last Update Date:2010-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA52501207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty