Basic Information
| Provider Information | |||||||||
| NPI: | 1124334107 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GOLDEN STATE SPORTS INJURY AND ORTHOPEDIC MEDICAL ASSOCIATES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2980 N BEVERLY GLEN CIR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900771726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104749809 | ||||||||
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| Practice Location | |||||||||
| Address1: | 18531 ROSCOE BLVD STE 202 | ||||||||
| Address2: | |||||||||
| City: | NORTHRIDGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913245950 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8189988400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2010 | ||||||||
| LastUpdateDate: | 10/19/2015 | ||||||||
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| AuthorizedOfficialLastName: | PERELMAN | ||||||||
| AuthorizedOfficialFirstName: | RONALD | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8189988400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GOLDEN STATE SPORTS INJURY AND ORTHOPEDIC MEDICAL ASSOCIATES, INC. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | Y | Suppliers | Non-Pharmacy Dispensing Site |
No ID Information.