Provider Demographics
NPI:1124265954
Name:BIOSTEM,INC
Entity type:Organization
Organization Name:BIOSTEM,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:STEPHENSON
Authorized Official - Middle Name:O
Authorized Official - Last Name:BAMIDELE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:866-894-7195
Mailing Address - Street 1:14111 FREEWAY DR STE 312
Mailing Address - Street 2:
Mailing Address - City:SANTA FE SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:90670-5822
Mailing Address - Country:US
Mailing Address - Phone:866-894-7195
Mailing Address - Fax:
Practice Address - Street 1:4000 LONG BEACH BVLD
Practice Address - Street 2:SUITE 226
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807
Practice Address - Country:US
Practice Address - Phone:866-894-7195
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-15
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARAML 2236-36207U00000X
CARAML 1258-19207UN0901X
CARHN 20032471N0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2471N0900XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistNuclear Medicine TechnologyGroup - Multi-Specialty
No207U00000XAllopathic & Osteopathic PhysiciansNuclear MedicineGroup - Multi-Specialty
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear CardiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========Medicaid
CA=========Medicaid