1619994449 NPI number — MOTION PICTURE AND TELEVISION FUND MEDICAL GROUP INC

Table of content: (NPI 1619994449)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619994449 NPI number — MOTION PICTURE AND TELEVISION FUND MEDICAL GROUP INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOTION PICTURE AND TELEVISION FUND MEDICAL GROUP 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:
WESTSIDE HEALTH CENTER
Provider Other Organization Name Type Code:
5
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:
1619994449
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/08/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
23388 MULHOLLAND DR
Provider Second Line Business Mailing Address:
MAILSTOP 62
Provider Business Mailing Address City Name:
WOODLAND HILLS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91364-2733
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-876-1636
Provider Business Mailing Address Fax Number:
818-876-1516

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1950 SAWTELLE BLVD
Provider Second Line Business Practice Location Address:
STE 130
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90025-7014
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-996-9355
Provider Business Practice Location Address Fax Number:
818-876-1516
Provider Enumeration Date:
07/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ELLIS
Authorized Official First Name:
SETH
Authorized Official Middle Name:
Authorized Official Title or Position:
VP CHIEF OPERATING OFFICER
Authorized Official Telephone Number:
818-876-1079

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: ZZZ09388Z . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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