Basic Information
| Provider Information | |||||||||
| NPI: | 1881164515 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MUSTAPHA | ||||||||
| FirstName: | IDRIS | ||||||||
| MiddleName: | ADELAJA | ||||||||
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| Credential: | LVN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 40 E MINARETS AVE | ||||||||
| Address2: | |||||||||
| City: | PINEDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936501239 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 40 E MINARETS AVE | ||||||||
| Address2: | |||||||||
| City: | PINEDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936501239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8553431057 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/26/2018 | ||||||||
| LastUpdateDate: | 02/01/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164X00000X | 697594 | CA | N | Nursing Service Providers | Licensed Vocational Nurse | 164X00000X | VN697594 | CA | Y | Nursing Service Providers | Licensed Vocational Nurse |
No ID Information.