Provider Demographics
NPI:1700519527
Name:SHAFE, JOHN MOJTABA
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MOJTABA
Last Name:SHAFE
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 1:3373 NIGHT BLOOM LN
Mailing Address - Street 2:
Mailing Address - City:PERRIS
Mailing Address - State:CA
Mailing Address - Zip Code:92571-3755
Mailing Address - Country:US
Mailing Address - Phone:949-800-9032
Mailing Address - Fax:
Practice Address - Street 1:3373 NIGHT BLOOM LN
Practice Address - Street 2:
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92571-3755
Practice Address - Country:US
Practice Address - Phone:949-800-9032
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-08
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8FSZ080343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)