Provider Demographics
NPI:1063692283
Name:MARIAM AMIRI
Entity type:Organization
Organization Name:MARIAM AMIRI
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIAM
Authorized Official - Middle Name:S
Authorized Official - Last Name:AMIRI
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:909-796-3707
Mailing Address - Street 1:PO BOX 1069
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-1069
Mailing Address - Country:US
Mailing Address - Phone:909-796-3707
Mailing Address - Fax:909-796-3709
Practice Address - Street 1:11332 MOUNTAIN VIEW AVE
Practice Address - Street 2:SUITE A
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3854
Practice Address - Country:US
Practice Address - Phone:909-796-3707
Practice Address - Fax:909-796-3709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-05
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA240000308261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ15754ZMedicare PIN