1396846762 NPI number — FUNCTIONAL RESTORATION MEDICAL CENTER, INC,

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396846762 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:
IRVINE OPEN MRI
Provider Other Organization Name Type Code:
3
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:
1396846762
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:
15825 LAGUNA CANYON RD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
IRVINE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92618-2125
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-777-9000
Provider Business Practice Location Address Fax Number:
949-777-9007
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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