Provider Demographics
NPI:1104986348
Name:SHANTI PRAKASH INC
Entity type:Organization
Organization Name:SHANTI PRAKASH INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HIREN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-856-3333
Mailing Address - Street 1:3932 DOWNING AVE
Mailing Address - Street 2:
Mailing Address - City:BALDWIN PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91706
Mailing Address - Country:US
Mailing Address - Phone:626-856-3333
Mailing Address - Fax:626-856-3355
Practice Address - Street 1:3932 DOWNING AVE
Practice Address - Street 2:
Practice Address - City:BALDWIN PARK
Practice Address - State:CA
Practice Address - Zip Code:91706
Practice Address - Country:US
Practice Address - Phone:626-856-3333
Practice Address - Fax:626-856-3355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACDC52501FMedicaid
CA55-2501Medicare ID - Type UnspecifiedMEDICARE ID NUMBER