Basic Information
| Provider Information | |||||||||
| NPI: | 1922069525 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IVEDCO, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | KABAFUSION TX | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 17777 CENTER COURT DR N | ||||||||
| Address2: | SUITE 550 | ||||||||
| City: | CERRITOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907039320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004353020 | ||||||||
| FaxNumber: | 5626455396 | ||||||||
| Practice Location | |||||||||
| Address1: | 4950 WESTGROVE DR | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752481924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003330660 | ||||||||
| FaxNumber: | 8888372716 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2006 | ||||||||
| LastUpdateDate: | 03/17/2021 | ||||||||
| 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: | 03/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | N | Agencies | Home Health | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 332BP3500X | N | Suppliers | Durable Medical Equipment & Medical Supplies | Parenteral & Enteral Nutrition | 3336C0003X | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 3336C0004X | N | Suppliers | Pharmacy | Compounding Pharmacy | 3336H0001X | N | Suppliers | Pharmacy | Home Infusion Therapy Pharmacy | 3336S0011X | N | Suppliers | Pharmacy | Specialty Pharmacy | 333600000X | Y | Suppliers | Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 100814810 C | 05 | OK | MEDICAID | 2104139 | 01 | PK | OTHER | 1218679-05 / 1922069 | 05 | TX | MEDICAID | 321002 | 05 | TX | MEDICAID | 100814810 A | 05 | OK | MEDICAID |