Provider Demographics
NPI:1255704276
Name:ELLEN MUSAKWA
Entity type:Organization
Organization Name:ELLEN MUSAKWA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FNP
Authorized Official - Prefix:
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MUSAKWA
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:951-966-0193
Mailing Address - Street 1:37657 BRUTUS WAY
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:CA
Mailing Address - Zip Code:92223-8056
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4121 BROCKTON AVE
Practice Address - Street 2:104
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-3442
Practice Address - Country:US
Practice Address - Phone:951-778-0032
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ELLEN MUSAKWA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-11-13
Last Update Date:2015-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95003212261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center