Provider Demographics
NPI:1952995086
Name:QASIM, AHMED AWAD
Entity Type:Individual
Prefix:
First Name:AHMED
Middle Name:AWAD
Last Name:QASIM
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 1:11545 DOVERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505-3205
Mailing Address - Country:US
Mailing Address - Phone:650-452-2554
Mailing Address - Fax:
Practice Address - Street 1:11545 DOVERWOOD DR
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-3205
Practice Address - Country:US
Practice Address - Phone:650-452-2554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-01
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
311ZA0620X
CA331881116320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA331881116OtherCDSS