Basic Information
| Provider Information | |||||||||
| NPI: | 1225239304 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAN BDNO MEDICAL ORTHOPAEDIC GROUP INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ARROWHEAD ORTHOPAEDICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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 310 | ||||||||
| Address2: | |||||||||
| City: | REDLANDS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923749706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095571600 | ||||||||
| FaxNumber: | 9095571740 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2007 | ||||||||
| LastUpdateDate: | 10/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | RAZZOUK | ||||||||
| AuthorizedOfficialFirstName: | NABIL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9095571601 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
| NPICertificationDate: | 10/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 369-1373-9 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0578500005 | 01 | CA | DME SUPPLIER | OTHER |