Basic Information
| Provider Information | |||||||||
| NPI: | 1285210427 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IVEDCO, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | KABAFUSION HH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 17777 CENTER COURT DR N STE 550 | ||||||||
| Address2: | |||||||||
| City: | CERRITOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907039337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004353020 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 317 LILAC DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | EDMOND | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730347210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4054942858 | ||||||||
| FaxNumber: | 4056793879 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2021 | ||||||||
| LastUpdateDate: | 09/30/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MASOOD | ||||||||
| AuthorizedOfficialFirstName: | SOHAIL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8004353020 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PHARM.D. | ||||||||
| NPICertificationDate: | 09/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | Y | Agencies | Home Health |
No ID Information.