Basic Information
| Provider Information | |||||||||
| NPI: | 1043806953 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ABDUL | ||||||||
| FirstName: | GAFOR | ||||||||
| MiddleName: | SIACOR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6777 ALAMAR WAY | ||||||||
| Address2: | |||||||||
| City: | ELK GROVE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 957586274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9168046026 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2150 STOCKTON BLVD | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958171337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9168751000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2020 | ||||||||
| LastUpdateDate: | 12/15/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.