Provider Demographics
NPI:1396201745
Name:ELJARRARI, MOURAD
Entity type:Individual
Prefix:
First Name:MOURAD
Middle Name:
Last Name:ELJARRARI
Suffix:
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 1:4101 BREMNER BLVD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23228-3609
Mailing Address - Country:US
Mailing Address - Phone:804-200-8043
Mailing Address - Fax:
Practice Address - Street 1:4101 BREMNER BLVD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23228-3609
Practice Address - Country:US
Practice Address - Phone:804-200-8043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-11
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAH123099344600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes344600000XTransportation ServicesTaxi