1205937752 NPI number — FUNCTIONAL RESTORATION MEDICAL CENTER, INC,

Table of content: (NPI 1205937752)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205937752 NPI number — FUNCTIONAL RESTORATION MEDICAL CENTER, INC,

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FUNCTIONAL RESTORATION MEDICAL CENTER, INC,
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205937752
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9134 W OLYMPIC BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEVERLY HILLS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90212-3540
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-432-1000
Provider Business Mailing Address Fax Number:
310-432-4321

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12828 HARBOR BLVD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
GARDEN GROVE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92840-5831
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-620-8200
Provider Business Practice Location Address Fax Number:
714-620-8211
Provider Enumeration Date:
09/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HEIKALI
Authorized Official First Name:
MOOSA
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
310-432-1000

Provider Taxonomy Codes

  • Taxonomy code: 261QR0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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