Basic Information
| Provider Information | |||||||||
| NPI: | 1285645606 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | YACOUB | ||||||||
| FirstName: | EMILE | ||||||||
| MiddleName: | IGNATIUS | ||||||||
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| Credential: | DPT OCS CSCS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 341 MAGNOLIA AVE | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | CORONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928793330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9517356060 | ||||||||
| FaxNumber: | 9517354510 | ||||||||
| Practice Location | |||||||||
| Address1: | 341 MAGNOLIA AVE | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | CORONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928793330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9517356060 | ||||||||
| FaxNumber: | 9517354510 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2006 | ||||||||
| LastUpdateDate: | 10/21/2008 | ||||||||
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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 | PT25573 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0PT255730 | 01 | CA | BLUE CROSS | OTHER | 0PT255730 | 01 | CA | BLUE SHIELD | OTHER |