Provider Demographics
NPI:1366082653
Name:BOWEN, ALFRED JR
Entity type:Individual
Prefix:
First Name:ALFRED
Middle Name:
Last Name:BOWEN
Suffix:JR
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 1:1111 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92701-4940
Mailing Address - Country:US
Mailing Address - Phone:214-669-0424
Mailing Address - Fax:
Practice Address - Street 1:2651 IRVINE AVE STE 122
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-6645
Practice Address - Country:US
Practice Address - Phone:214-669-0424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-14
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA74630225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAPI-ABMP-17OtherASSOCIATED BODYWORK & MASSAGE PROFESSIONALS