Provider Demographics
NPI:1043959786
Name:FAWAZ, YOLA
Entity type:Individual
Prefix:
First Name:YOLA
Middle Name:
Last Name:FAWAZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:167 N 3RD AVE STE R
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-6052
Mailing Address - Country:US
Mailing Address - Phone:818-824-2362
Mailing Address - Fax:
Practice Address - Street 1:167 N 3RD AVE STE R
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-6052
Practice Address - Country:US
Practice Address - Phone:818-824-2362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-01
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26280111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA90775518G21244Medicaid