Basic Information
| Provider Information | |||||||||
| NPI: | 1124194618 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HANNAWAY | ||||||||
| FirstName: | BASSAM | ||||||||
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| Credential: | MPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8520 | ||||||||
| Address2: | |||||||||
| City: | REDLANDS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923751720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095571600 | ||||||||
| FaxNumber: | 9095571740 | ||||||||
| Practice Location | |||||||||
| Address1: | 1901 W LUGONIA AVE STE 130 | ||||||||
| Address2: | |||||||||
| City: | REDLANDS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923749704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095571600 | ||||||||
| FaxNumber: | 9095571740 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/27/2006 | ||||||||
| LastUpdateDate: | 09/17/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT25186 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | ZZZ29668Z | 01 | CA | MEDICARE PTAN | OTHER |