Provider Demographics
NPI:1154927192
Name:4000 MOUNT ELENA CIRCLE CORONA, CA 92882
Entity type:Organization
Organization Name:4000 MOUNT ELENA CIRCLE CORONA, CA 92882
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALICE
Authorized Official - Middle Name:K
Authorized Official - Last Name:YOUSSEF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-993-5823
Mailing Address - Street 1:4000 MOUNT ELENA CIR
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92882-7916
Mailing Address - Country:US
Mailing Address - Phone:626-993-5823
Mailing Address - Fax:
Practice Address - Street 1:4000 MOUNT ELENA CIR
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92882-7916
Practice Address - Country:US
Practice Address - Phone:626-993-5823
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-07
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Multi-Specialty